Questions & answers · Health insurance
What happens after my Medicare Advantage plan keeps its denial on appeal?
Health insuranceAppealChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: 42 CFR 422.590 (eCFR (current as of 2026-11-02)) · § 422.590(a)(2) View original ↗
In short
- If the plan keeps its denial, it sends your case to an outside reviewer.
- You do not file that step yourself.
- After that, you have 60 days to go to the next level.
What this means
If your plan keeps its denial, in whole or in part, it must send your case file to an independent entity that CMS contracts with. This is Level 2. The plan sends it for you [1]. Starting May 1, 2026, that entity is C2C Innovative Solutions, Inc. (C2C). MAXIMUS still handles requests received on or before April 30, 2026 [2]. If you disagree with the Level 2 decision, you have 60 days from the date of that decision to ask for Level 3, a decision by the Office of Medicare Hearings and Appeals (OMHA). For 2026, your case must be worth at least $200 [3]. After Level 3, you have 60 days after you get the decision to ask the Medicare Appeals Council for a Level 4 review [4]. After Level 4, you have 60 days after you get the Appeals Council's decision to ask a federal district court for review. This is Level 5. For 2026, your case must be worth at least $1,960. You may be able to combine claims to reach that amount [4].
Where this comes from (4)
[1] 42 CFR 422.590 (eCFR (current as of 2026-11-02)) · § 422.590(a)(2) · checked 2026-11-05
If the MA organization makes a reconsidered determination that affirms, in whole or in part, its adverse organization determination, it must prepare a written explanation and send the case file to the independent entity contracted by CMS
[2] Medicare Managed Care Appeals & Grievances · What's New (5/1/2026) · page last modified 07/06/2026 · checked 2026-11-05
Effective May 1, 2026, C2C Innovative Solutions, Inc. (C2C) is the Part C IRE. The former Part C IRE, MAXIMUS, will continue to process appeal requests received on or before April 30, 2026.
[3] Appeals in Medicare health plans · Level 2 › If you disagree; Level 3 · checked 2026-11-05
You have 60 days from the date of the IRE’s decision to ask for a level 3 appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA). … For 2026, the minimum dollar amount is $200.
[4] Appeals in Medicare health plans · Level 3 (end) · Level 4 · Level 5 · checked 2026-11-05
You have 60 days after you get the decision to move to appeals level 4, by asking for a review by the Medicare Appeals Council … You can request judicial review in Federal district court (level 5) if: … For 2026, the minimum dollar amount is $1,960. You may be able to combine claims to meet this dollar amount. You have 60 days after you get the Appeals Council's decision to ask for judicial review by a federal distri…
How we found this
We matched your question to 4 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.
What we don’t know yet
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Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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