Level 2 Appeals: Medicare Advantage (Part C)
The Level 2 claim appeals process differs based on what Part of Medicare you want to appeal.
Who Conducts Level 2 Appeals (e.g., "reconsidered determination")
An Independent Review Entity (IRE) retained by CMS, will conduct the Level 2 appeal, called a reconsidered determination in Medicare Part C. IREs have their own doctors and other health professionals to independently review and assess the medical necessity of the items and services pertaining to your case.
For more information about filing a Level 2 appeal, visit the "Appeals and Grievances" section of Medicare.gov.
Automatic Forward to Level 2 Appeals
Your Level 1 appeal ("reconsideration") will automatically be forwarded to Level 2 of the appeals process in the following instances:
Your plan does not meet the response deadline.
If your Medicare Advantage plan fails to meet the established deadlines, it is required to forward your appeal to an independent outside entity for a Level 2 review.
Your plan does not decide in your favor.
If during your Level 1 appeal ("reconsideration") your Medicare Advantage plan does not decide in your favor, it is required to forward your appeal to an independent outside entity for a Level 2 review.
Response to Your Appeal
After it has reviewed your case, the Independent Review Entity (IRE) will send you a notice of its decision in the mail.
Appealing to the Next Level of Appeals
The IRE notice will contain detailed information about your right to appeal to OMHA (Level 3). You may appeal to Level 3 in writing if:
- You are dissatisfied with the IRE’s decision, and
- The amount in controversy is $150 or more (in 2015), and
- Less than 60 days have passed since you received the reconsideration determination.
Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.