How to appeal a Medicare Advantage denial
Medicare Advantage appeals follow a five-level process set by CMS, and non-contracted providers must attach a Waiver of Liability or the appeal is dismissed without review.
Deadlines
These are the windows Medicare Advantage publishes. They vary by contract, product line and state — so treat the date on your remittance advice as the one that governs.
- Level 1 reconsideration request
- commonly 60 calendar days from the denial
- For non-contracted providers. Contracted providers generally follow the dispute process in their agreement instead.
- Waiver of Liability
- within 60 calendar days of the appeal request
- If the plan does not receive it in time, the appeal is forwarded for dismissal — the merits are never reached.
- Plan's response
- commonly 60 calendar days for payment reconsiderations
- Pre-service and expedited requests run on much shorter clocks.
The appeal path
- 01
Level 1 — Plan reconsideration
The plan reviews its own determination. Non-contracted providers must include a signed Waiver of Liability statement.
- 02
Level 2 — Independent Review Entity
If the plan does not decide fully in your favor, it must forward the case to the CMS-contracted Independent Review Entity. This escalation is automatic — you do not request it.
- 03
Level 3 — Administrative Law Judge
A hearing before an ALJ at the Office of Medicare Hearings and Appeals, subject to an amount-in-controversy threshold.
- 04
Level 4 — Medicare Appeals Council
Review by the Council within the Departmental Appeals Board.
- 05
Level 5 — Federal district court
Judicial review, subject to a higher amount-in-controversy threshold.
Where to submit
- The plan's Medicare Advantage appeals address, as printed on the denial notice
- The plan's provider portal, where it accepts Medicare Advantage appeals
- The Waiver of Liability form the plan publishes, for non-contracted providers
What to include
- A signed Waiver of Liability statement, if you are non-contracted
- The remittance advice and the denial notice
- Clinical documentation supporting the service
- The applicable coverage determination, where the denial cites one
What catches practices out
- The Waiver of Liability is the single biggest trap. Without it, a non-contracted provider's appeal is dismissed on procedure and the clinical argument is never read.
- Escalation to the Independent Review Entity is automatic when the plan does not rule fully in your favor — practices sometimes refile at Level 1 instead of waiting for a case already moving.
- Contracted and non-contracted providers follow different paths on the same plan. Confirm your status before using either.
- Prior-authorization denials now sit under the CMS-0057-F decision timeframes that took effect January 1, 2026 — a plan that missed its own deadline is a live argument.
Denial codes you will see most from Medicare Advantage
Common questions
- What is a Waiver of Liability and why does it matter?
- It is a statement in which a non-contracted provider agrees not to bill the member regardless of the appeal outcome. Medicare Advantage plans require it with the appeal, and if it does not arrive within 60 calendar days the appeal is forwarded for dismissal — meaning the denial is never reviewed on its merits.
- How many levels are there in a Medicare Advantage appeal?
- Five: plan reconsideration, the CMS Independent Review Entity, an Administrative Law Judge hearing, the Medicare Appeals Council, and federal district court. Levels three and five carry amount-in-controversy thresholds.
- Do I have to request the second-level review?
- No. If the plan does not decide fully in your favor, it is required to forward the case to the Independent Review Entity automatically. Refiling at level one instead just delays a case that is already moving.
- Does this differ from Original Medicare?
- Yes. Medicare Advantage appeals run through the plan first, whereas Original Medicare claims start with the contractor's redetermination. Confirm which the patient has before starting.
Draft the Medicare Advantage appeal in about three minutes
Upload the denial. Undeny reads it, drafts an appeal letter built around the denial code and the record, and tracks the deadline until the money comes back.