Reconsideration by the Medicare Advantage (Part C) Health Plan

If a Medicare health plan denies an enrollee's request (issues an adverse organization determination) for an item or service, in whole or in part, the enrollee, enrollee’s representative, or enrollee’s physician may appeal the decision to the plan by requesting a standard or expedited reconsideration. If a physician requests the expedited reconsideration, plans are required to expedite the request. 

How to Request a Reconsideration

Reconsideration requests must be filed with the health plan within 65 calendar days from the date of the notice of the organization determination.  Standard requests must be made in writing, unless the enrollee's plan accepts verbal requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts verbal standard requests.  Expedited requests can be made either verbally or in writing.  

How a Health Plan Processes Reconsideration Requests

Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee's health requires, but no later than 72 hours for expedited pre-service benefit or Part B drug requests, 30 calendar days for standard pre-service requests, 7 calendar days for standard Part B drug requests, or 60 calendar days for payment requests.

If the decision is unfavorable to the enrollee, in whole or in part, the plan must submit the case file and its decision for automatic review by the Part C Independent Review Entity (IRE).

For more information about health plan reconsiderations and appointment of a representative, see section 50 and section 20 (respectively) in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the "Downloads” section below.