If your Medicare Advantage or Part D plan has upset you or turned down something you need, the route forward depends on what went wrong: Medicare Advantage grievances and appeals are two separate processes with different deadlines, and picking the wrong one costs you time. A grievance is a complaint about how the plan treated you. An appeal is a request to overturn a decision that denied, reduced, or stopped your coverage.
Grievance or Appeal: Which One Fits
Long hold times, rude staff, a dirty facility, trouble getting a timely appointment — those are grievances. The plan mishandled something, but it didn’t refuse to cover a service or drug.
An appeal is what you file when the plan won’t authorize a procedure, won’t pay a claim, drops a drug from coverage, or imposes restrictions you disagree with. The two tracks don’t overlap, and the timelines are completely different, so identifying which one you actually need is the first decision to make.
Filing a Grievance
You can file a grievance with your plan by phone or in writing. The deadline is 60 calendar days from the event that prompted the complaint. The plan then has 30 calendar days to resolve it and tell you the outcome.1eCFR. 42 CFR 422.564 – Grievance Procedures
The plan can extend that 30-day window by up to 14 more calendar days if you ask for more time or if the plan needs additional information and can document that the delay works in your interest. When it extends, it must notify you in writing right away and explain why.1eCFR. 42 CFR 422.564 – Grievance Procedures
Some grievances get a 24-hour response. That short clock applies when your complaint is about the plan refusing to grant an expedited coverage decision or expedited appeal, or when the plan invokes a time extension on a pending coverage decision or reconsideration.1eCFR. 42 CFR 422.564 – Grievance Procedures
If the complaint is about the quality of care you received, you have a second option: file directly with the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), which reviews quality concerns independently.2Centers for Medicare & Medicaid Services. Beneficiary and Family Centered Care (BFCC)-QIOs
Appealing a Denied Medical Service (Part C)
When your Medicare Advantage plan makes an initial decision about covering a service or paying a claim, that decision is called an organization determination. A denial notice must explain the reason and your appeal rights.
Requesting a Reconsideration
The first-level appeal is a reconsideration. You or your representative have 60 calendar days from receiving the denial to file, and the plan presumes you received the notice five days after the date on it.3Centers for Medicare & Medicaid Services. Reconsideration by the Medicare Advantage (Part C) Health Plan Your treating physician can also file a pre-service reconsideration as long as they notify you.
How fast the plan must decide depends on what you’re asking for:
- Standard pre-service request: 30 calendar days.
- Standard Part B drug request: 7 calendar days.
- Payment request (service already received): 60 calendar days.
- Expedited request: 72 hours.
Those deadlines come from 42 CFR 422.590.4eCFR. 42 CFR 422.590 – Timeframes and Responsibility for Reconsiderations The Part B drug category is easy to miss because it sits between the standard and expedited tracks with a much shorter clock than other pre-service requests.3Centers for Medicare & Medicaid Services. Reconsideration by the Medicare Advantage (Part C) Health Plan
Asking for Expedited Review
You can request an expedited reconsideration when waiting for the standard timeframe could seriously harm your health or your ability to regain function. If the plan or your physician agrees, the decision must come within 72 hours.3Centers for Medicare & Medicaid Services. Reconsideration by the Medicare Advantage (Part C) Health Plan If the plan refuses expedited handling, it must process the case on the standard timeframe and tell you that you can grieve the refusal, which triggers the 24-hour grievance rule.
What Happens if the Plan Still Says No
If the plan upholds its denial on reconsideration, it must automatically forward your case file and its decision to an Independent Review Entity. You don’t have to do anything to reach that second level of review.3Centers for Medicare & Medicaid Services. Reconsideration by the Medicare Advantage (Part C) Health Plan
Appealing a Denied Prescription Drug (Part D)
Part D follows a similar structure but with different terminology and shorter clocks. The plan’s initial decision is a coverage determination. If it goes against you, the first-level appeal is called a redetermination.
Filing a Redetermination
You have 60 calendar days from receiving the denial to file.5Centers for Medicare & Medicaid Services. Redetermination by the Part D Plan Sponsor Your prescribing physician can file for you. Part D appeals often involve exception requests: asking the plan to cover a non-formulary drug, waive a prior authorization or quantity limit, or apply a lower cost-sharing tier.
For any exception, your prescriber must submit a supporting statement explaining why the drug is medically necessary. For a tier exception, the statement has to explain why the lower-tier alternative wouldn’t be as effective or would cause adverse effects.
The plan’s decision deadlines:
- Standard request for drug benefits: 7 calendar days.
- Standard request for payment: 14 calendar days.
- Expedited request: 72 hours.
The expedited track applies when the plan determines, or your prescriber tells the plan, that a standard timeframe could seriously jeopardize your health.5Centers for Medicare & Medicaid Services. Redetermination by the Part D Plan Sponsor
What if the Plan Misses Its Deadline
Part D has a protection worth knowing about. If the plan doesn’t issue its redetermination within the required time, the failure counts as an adverse decision, and the plan must forward your request to the Independent Review Entity within 24 hours.6eCFR. 42 CFR 423.590 – Timeframes and Responsibility for Making Redeterminations That rule covers both standard and expedited requests. A slow plan doesn’t get a longer clock; it loses control of the decision.
Independent Review Entity
The Independent Review Entity (IRE) is an outside organization CMS contracts with. For Part C, the plan sends unfavorable reconsiderations to the IRE automatically.7Centers for Medicare & Medicaid Services. Reconsideration by Part C Independent Review Entity (IRE) For Part D, the denial notice will tell you how to request IRE review; automatic forwarding applies only to certain drug management program determinations.5Centers for Medicare & Medicaid Services. Redetermination by the Part D Plan Sponsor
The IRE works under the same timeframes that applied at the plan level: for Part C, 30 days on standard pre-service, 7 days on Part B drugs, 60 days on payment, and 72 hours on expedited requests, counted from when the IRE receives the case.7Centers for Medicare & Medicaid Services. Reconsideration by Part C Independent Review Entity (IRE) For Part D, the IRE has 7 calendar days on standard requests and 72 hours on expedited requests.8eCFR. 42 CFR 423.600 – Reconsideration by an Independent Review Entity (IRE)
Higher Levels if the IRE Rules Against You
The process doesn’t end at the IRE. Three more levels of review are available, each adding procedural requirements.
Administrative Law Judge Hearing
After an unfavorable IRE decision, you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. The amount in dispute has to meet a minimum threshold, which for 2026 is $200.9Federal Register. Medicare Appeals Adjustment to the Amount in Controversy Threshold Amounts Multiple denied claims can be combined to reach it. Form OMHA-100 is available for filing the request, though not required.10HHS.gov. Tips for Filing a Request for ALJ Hearing or Review of Dismissal
Medicare Appeals Council
If the ALJ rules against you, the next step is the Medicare Appeals Council. File a written request within 60 calendar days of receiving the ALJ decision, with the same five-day mailing presumption. The Council generally has 90 calendar days to issue its decision.11eCFR. 42 CFR Part 405 Subpart I – Medicare Appeals Council Review
Federal District Court
The final level is judicial review in federal district court. You have 60 calendar days from receiving the Council’s decision, and the amount in controversy has to meet a higher threshold: $1,960 for cases filed in 2026.9Federal Register. Medicare Appeals Adjustment to the Amount in Controversy Threshold Amounts Most enrollees will want legal representation at this stage, since it operates under the rules of federal civil litigation.
Fast-Track Appeals When Ongoing Care Is Being Cut Off
A separate expedited route exists when the plan is ending coverage for care you’re currently receiving, typically an inpatient hospital stay, skilled nursing care, home health services, or outpatient rehab. You should get a termination notice at least two days before coverage ends, and you can ask the BFCC-QIO for an immediate review instead of going through the plan’s internal reconsideration.12Centers for Medicare & Medicaid Services. Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) Review
Timing is what matters. For a hospital discharge, you have to contact the BFCC-QIO by midnight on the day listed as your discharge date. If you file before the termination takes effect, you generally won’t be financially responsible for the disputed services during the review. Miss the deadline and you can still appeal, but you may be liable for costs after the termination date. The plan carries the burden of justifying the end of coverage.
Letting Someone Act on Your Behalf
You can appoint a family member, friend, attorney, or advocate to handle this for you at any stage. The standard method is CMS Form 1696, signed by both of you. The appointment lasts one year from signing and can be used across multiple grievances or appeals in that window.13Centers for Medicare & Medicaid Services. Appointment of Representative (Form CMS-1696)
Your representative has the same rights you do at every level. Your treating physician can file a pre-service reconsideration without a formal appointment as long as they notify you. If someone shows up as your representative without proper paperwork, the plan still has to process expedited requests without delay while the documentation gets sorted.
Making Sure a Favorable Decision Gets Carried Out
Winning doesn’t matter if the plan drags its feet. Plans have to implement favorable decisions within the same timeframes that governed the appeal. For Part C, a favorable standard pre-service reconsideration must be effectuated within 30 calendar days, a Part B drug reconsideration within 7 days, and an expedited reconsideration within 72 hours.4eCFR. 42 CFR 422.590 – Timeframes and Responsibility for Reconsiderations For Part D, favorable standard redeterminations must be carried out within 7 calendar days on drug benefit requests and 72 hours on expedited requests.6eCFR. 42 CFR 423.590 – Timeframes and Responsibility for Making Redeterminations
The same rule applies when the IRE or a higher decision-maker reverses the plan. If your plan won’t act on a favorable ruling, that’s itself a grievance you can file and escalate.