Medicare Advantage (MA) enrollment continues to increase, with more than half of eligible patients choosing MA plans over traditional fee-for-service Medicare. Under federal law, MA plans are required to cover all services that are covered by traditional Medicare. However, MA plans can — and often do — employ utilization management tools, including prior authorization, to delay or deny coverage of medically necessary items and services. As a result, allergists and other healthcare professionals frequently encounter prior authorization denials and claim denials when treating MA enrollees.
To effectively advocate for their patients and to secure appropriate reimbursement, clinicians must understand the MA appeals framework. The MA appeals process consists of five levels:
- Reconsideration by the MA plan
- Reconsideration by the Independent Review Entity
- Administrative Law Judge (ALJ) hearing
- Medicare Appeals Council (Council) review
- Federal District Court review
Reconsideration by the MA plan
Appeal rights
An allergist’s appeal rights differ depending on whether they are seeking payment after providing a service (termed a payment determination) or seeking prior authorization from the plan before providing a service (a prior authorization determination).
Although treating physicians and other qualified healthcare professionals (QHP) have appeal rights in the MA appeals process, they are significantly more limited than the appeal rights afforded to MA enrollees. Under the MA appeal framework, an allergist’s appeal rights largely depend on whether the physician and/or QHP has a contract with the MA plan.
- Payment denials:
- Non-Contract: If the MA plan denies a request for payment from a non-contract allergist, the non-contract allergist may independently pursue an appeal if a Waiver of Liability (WOL) statement is filed. This statement provides that the non-contract practitioner will not bill the MA enrollee regardless of the outcome of the appeal.
- Contract: For contract allergists, payment disputes are governed by the appeals/dispute resolution provisions in the contract between the allergist and the plan. This article does not address contract resolution provisions.
- Prior authorization denials:
- For both contract and non-contract allergists, the physician who is providing treatment to an enrollee may, upon providing notice to the enrollee, appeal on the enrollee’s behalf.
Initial plan determination
Medicare requires MA plans to make payment and prior authorization determinations within established deadlines:
- Payment denials:
- For non-contracted allergists, the MA plan generally must pay 95% of “clean claims” within 30 days; all other claims must be paid or denied within 60 days.
- Prior authorization denials:
- When a contracted or non-contracted allergist is requesting prior authorization, the plan must generally render a decision within:
- 7 days for a service beginning Jan. 1, 2026.
- 72 hours for a Part B drug.
- In emergency situations, the plan must follow an expedited process under which determinations must be made within:
- 72 hours for services.
- 24 hours for Part B drugs.
- When a contracted or non-contracted allergist is requesting prior authorization, the plan must generally render a decision within:
If the MA plan denies a claim due to a medical necessity, the denial must have been reviewed by a physician or other appropriate healthcare professional with expertise in the field of medicine or healthcare that is appropriate for the services at issue, including knowledge of Medicare coverage criteria. The reviewer must have a current and unrestricted license. The reviewer, however, is not required to be of the same specialty or subspecialty as the treating physician.
Reconsideration by the Independent Review Entity
If the MA plan denies a request for payment or prior authorization, the allergist may request reconsideration by the plan.
- Payment denials:
- A non-contract practitioner may request a reconsideration of the MA plan’s denial of payment within 65 days from the remittance notification date.
- The plan must render a determination within 60 days.
- Prior authorization denials:
- A practitioner must file a request for reconsideration within 65 days from the date of the notice of the initial determination. The appellant may submit additional evidence to the MA plan.
- The plan must render a determination within:
- 30 days for standard item, service, or Part D drug requests.
- 7 days for standard Part B drug requests.
- 72 hours for expedited requests.
Independent Review Entity reconsideration
If the MA plan upholds its denial, the case will be automatically transferred to an independent review entity. In other words, the appellant does not need to make a request for a level 2 appeal. Effective May 1, 2026, C2C Innovative Solutions, Inc. (C2C) is the Part C independent review entity.
- Payment denials:
- The independent review entity must issue a decision within 60 days.
- Prior authorization denials:
- The independent review entity must issue a decision within:
- 30 days for standard item, service, or Part D drug requests.
- 7 days for standard Part B drug requests.
- 72 hours for expedited requests.
- The independent review entity must issue a decision within:
Administrative law judge (ALJ) hearing
If the independent review entity’s decision is unfavorable, a written request for an ALJ hearing may be submitted within 60 days of receiving the decision. An ALJ is a specialized judge within the Department of Health and Human Services’ Office of Medicare Hearings and Appeals (OMHA). For the claim to be considered by the ALJ, it must meet a minimum dollar amount, which is adjusted annually for inflation. For 2026, this value is $200.
The ALJ stage is arguably the most important level of the Medicare appeals process because it is the first opportunity for an independent judge to conduct a hearing, allow the physician and other witnesses to provide verbal testimony, and ask questions. The appellant may be represented by an attorney during the hearing. After the hearing, the ALJ will issue a written decision affirming or denying the independent review entity’s determination in whole or in part. By law, an ALJ must issue a decision within 90 days of receiving a request for a hearing. However, these decisions are frequently delayed due to a backlog of cases.
Medicare Appeals Council (Council) review
An unfavorable ALJ decision can be appealed to the Council within 65 days of the date of the ALJ’s decision. Notably, the MA plan may appeal to the Council if it loses at the ALJ level. Unlike the ALJ level, there is not a hearing held at this stage. By law, the Council must issue a decision within 90 days of receiving a request for review. However, these decisions have been delayed due to a backlog of cases.
Federal district court review
If the Council’s decision is unfavorable, a lawsuit may be filed in federal district court within 65 days of the Council’s decision. In practice, this rarely occurs as the litigation process is lengthy, legal fees are considerable, and the amount in controversy must meet a threshold ($1,900 in 2025).
The Advocacy Council encourages allergists to learn the Medicare Advantage appeals framework in order to effectively advocate for their patients and to secure appropriate reimbursement for their practices.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
