Reconsideration by the Medicare Advantage (Part C) Health Plan

If a Medicare health plan denies an enrollee's request for an item or service in whole or in part (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration. 

An enrollee or an enrollee's representative may request a standard or expedited reconsideration.

An enrollee's physician may request an expedited or a standard reconsideration, without being appointed as the enrollee's representative, on the enrollee's behalf.  If a physician requests the expedited reconsideration, plans are required to expedite the request. 

For more information about reconsiderations, including appointing a representative, see section 60.1.1 in Chapter 13 of the Medicare Managed Care Manual in the "Downloads” section below.

How to Request a Reconsideration
Reconsideration requests must by filed with the health plan within 60 calendar days from the date of the notice of the organization determination.

Expedited requests can be made either orally or in writing.

Standard requests must be made in writing, unless the enrollee's plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests.

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 72 hours for expedited requests or 30 calendar days for standard 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).

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about reconsiderations by the IRE or any other level of the appeals process.