Georgia Medicare Appeals Process: 5-Level Federal Appeals Framework

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By Brevy Care Team · Last verified May 13, 2026

The Medicare appeals process is one of the most important consumer protections in American health insurance. Under Section 1869 of the Social Security Act (42 USC 1395ff) and Section 1852(g) of the Social Security Act (42 USC 1395w-22(g)) and Section 1860D-4(g), every Medicare beneficiary has the right to appeal an adverse coverage determination through a structured five-level federal appeals framework. The five levels are codified at 42 CFR Part 405 Subpart I (Original Medicare), 42 CFR Part 422 Subpart M (Medicare Advantage), and 42 CFR Part 423 Subpart M (Part D). At Level 1, the beneficiary requests redetermination from the Medicare Administrative Contractor (Original Medicare) or reconsideration from the plan (Medicare Advantage or Part D). At Level 2, an independent contractor reviews the case: the Qualified Independent Contractor (C2C Innovative Solutions) for Original Medicare Parts A and B, or the Independent Review Entity (Maximus Federal Services) for Medicare Advantage and Part D. At Level 3, an Administrative Law Judge at the HHS Office of Medicare Hearings and Appeals hears the case. At Level 4, the Medicare Appeals Council at the HHS Departmental Appeals Board reviews. At Level 5, the beneficiary may file suit in federal district court. Amount in controversy thresholds (updated annually by CMS) apply at Levels 3 and 5. Critical deadlines: 120 days to file Level 1 redetermination in Original Medicare; 60 days for most other filings. Expedited timelines apply for urgent matters: 72 hours for expedited plan reconsideration and IRE review in Medicare Advantage and Part D. For Georgia Medicare beneficiaries, the appeals process is the structural protection that turns the rules on paper into enforceable rights. This guide explains the federal authorities, each of the five levels in detail, the deadlines and thresholds, the role of the Independent Review Entity and Qualified Independent Contractor, the role of the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council, expedited appeals, good cause for late filing, the right to representation, and worked examples for typical Georgia appeals scenarios. :::

::: callout Key takeaways for Georgia Medicare appeals process

• Medicare appeals follow a five-level federal framework under Section 1869 SSA (Original Medicare), Section 1852(g) SSA (Medicare Advantage), and Section 1860D-4(g) SSA (Part D), codified at 42 CFR Parts 405, 422, and 423.
• Level 1 is redetermination (Original Medicare) or plan reconsideration (Medicare Advantage and Part D).
• Level 2 is reconsideration by the Qualified Independent Contractor (Original Medicare; C2C Innovative Solutions at 1-866-251-4292) or the Independent Review Entity (Medicare Advantage and Part D; Maximus Federal Services at 1-833-919-0198).
• Level 3 is an Administrative Law Judge hearing through the HHS Office of Medicare Hearings and Appeals (OMHA at 1-855-556-8475). An amount in controversy threshold applies (updated annually by CMS).
• Level 4 is review by the Medicare Appeals Council through the HHS Departmental Appeals Board (202-565-0200).
• Level 5 is federal district court review under Section 205(g) SSA. A higher amount in controversy threshold applies (updated annually by CMS).
• Filing deadlines: 120 days for Original Medicare redetermination (Level 1); 60 days for most other levels.
• Expedited timelines apply when health is at risk: 72 hours for plan reconsideration and IRE review in Medicare Advantage and Part D.
• GeorgiaCares (1-866-552-4464) provides free unbiased counseling on Medicare appeals; Atlanta Legal Aid (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal representation for low-income beneficiaries. :::

Why the Medicare appeals process matters

Medicare is a federal benefit, and federal benefits trigger due process protections under the Fifth Amendment of the United States Constitution. The Supreme Court established the basic due process framework for benefit appeals in Goldberg v. Kelly (397 US 254, 1970), holding that public benefit recipients are entitled to procedural protections before benefits can be terminated. The Court refined the framework for federal benefits in Mathews v. Eldridge (424 US 319, 1976), establishing the balancing test that weighs the private interest, the risk of erroneous deprivation, and the government interest in administrative efficiency.

The Medicare appeals process is the procedural protection that flows from these due process foundations. When a Medicare plan or contractor denies a service or refuses to pay a claim, the beneficiary has the right to challenge that decision through a structured administrative process culminating in federal court review. The process is intentionally redundant: multiple levels of review reduce the risk of erroneous denials. The process is intentionally independent: Level 2 review is conducted by contractors independent of the original decision-maker. The process is intentionally accessible: filing requires no special legal expertise at the lower levels, and beneficiaries can represent themselves or use representatives including family members.

The framework matters because Medicare denials are common, and many of them are wrong. Government oversight reports have found that a substantial proportion of Medicare Advantage prior authorization denials concerned services that Original Medicare would have covered, and that many appealed denials are ultimately reversed in favor of the beneficiary. The high reversal rate suggests that many initial denials are issued in error or based on overly restrictive plan-specific criteria. The appeals process is the mechanism that corrects those errors.

The five-level framework

The Medicare appeals process has five levels for Original Medicare, Medicare Advantage, and Part D. The structure is parallel across all three programs, though the specific contractors and timelines differ.

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The starting point is always Level 1. Beneficiaries cannot skip levels. The case proceeds level by level. If the decision at any level is favorable to the beneficiary, the appeal stops at that level. If the decision is unfavorable, the beneficiary may continue to the next level.

The amount in controversy thresholds apply at Levels 3 and 5. Both thresholds are updated annually by CMS; check CMS.gov for the current year amounts. Multiple claims may be aggregated to meet the thresholds when they involve the same beneficiary or the same matter.

Level 1: redetermination or plan reconsideration

Level 1 is the starting point for any Medicare appeal. For Original Medicare, Level 1 is called "redetermination" and is conducted by the Medicare Administrative Contractor that made the initial determination. For Georgia, the Original Medicare MAC for Parts A and B is Palmetto GBA (1-855-696-0705). For Medicare Advantage and Part D, Level 1 is called "plan reconsideration" and is conducted by the plan itself.

The deadline for filing Level 1 differs across programs. Original Medicare allows 120 days from the initial determination to file a redetermination. Medicare Advantage and Part D allow 60 days from the denial notice to file a plan reconsideration. The shorter timeline for Medicare Advantage and Part D reflects the more compressed structure of those programs, where plans manage the entire process administratively.

The response time also differs across programs. For Original Medicare, the MAC has 60 days to issue a redetermination. For Medicare Advantage, the plan has 30 days for standard pre-service reconsiderations, 60 days for payment reconsiderations, and 72 hours for expedited reconsiderations. For Part D, the plan has 7 days for standard reconsiderations and 72 hours for expedited reconsiderations.

Under the CMS 2024 Medicare Advantage Final Rule, plan reconsiderations involving clinical denials must be reviewed by a physician with appropriate specialty expertise. Oncology denials must be reviewed by an oncologist. Cardiac denials must be reviewed by a cardiologist. The specialty review requirement strengthens the integrity of the Level 1 reconsideration process.

To file Level 1, the beneficiary submits a written request to the appropriate party. For Original Medicare, the request goes to Palmetto GBA at the address on the Medicare Summary Notice (MSN). For Medicare Advantage, the request goes to the plan at the address in the Evidence of Coverage. For Part D, the request goes to the Part D plan. The request should include the beneficiary's identification, the determination being appealed, the basis for the appeal, and supporting evidence (medical records, physician statements, billing records).

Level 2: QIC or IRE reconsideration

Level 2 is conducted by a contractor independent of the original decision-maker. For Original Medicare Parts A and B, Level 2 is conducted by the Qualified Independent Contractor (QIC). The QIC for Georgia Original Medicare Part A and Part B is C2C Innovative Solutions (1-866-251-4292). For Medicare Advantage and Part D, Level 2 is conducted by the Independent Review Entity (IRE). The IRE for both Medicare Advantage and Part D is Maximus Federal Services (1-833-919-0198).

The deadline and response time at Level 2 differ across programs. For Original Medicare, the beneficiary has 180 days from the Level 1 redetermination to file a Level 2 reconsideration with the QIC, and the QIC has 60 days to respond. For Medicare Advantage, the case is automatically forwarded from the plan to the IRE if the plan upholds the denial at Level 1, and the IRE has 30 days for standard reconsiderations and 72 hours for expedited reconsiderations. For Part D, the beneficiary has 60 days from the plan's Level 1 decision to file with the IRE, and the IRE has 7 days for standard reconsiderations and 72 hours for expedited reconsiderations.

The independence of the QIC and IRE is a critical feature of the appeals process. The Level 1 reviewer (MAC or plan) has institutional incentives that may bias the decision. The Level 2 reviewer is contractually obligated to apply the same Medicare coverage rules without regard to the original decision-maker's interests. The independence is enforced through CMS contracting standards and audit processes.

Maximus Federal Services as the Medicare Advantage and Part D IRE has been the subject of substantial public commentary. Some advocacy organizations have raised concerns about IRE consistency and the speed of decisions. Others have noted that the IRE plays a critical role in correcting plan errors and that its decisions are generally well-reasoned. Government oversight data indicates that a substantial portion of appealed MA prior authorization denials are reversed somewhere in the appeals process, and a significant portion of those reversals come at the IRE level.

The QIC for Original Medicare Parts A and B (C2C Innovative Solutions) plays an analogous role. The QIC reviews the case independently of the MAC, considers any new evidence submitted, and issues a decision. The QIC decision is binding unless the beneficiary appeals to Level 3.

Level 3: ALJ hearing through OMHA

Level 3 is an Administrative Law Judge hearing through the HHS Office of Medicare Hearings and Appeals (OMHA at 1-855-556-8475). OMHA is independent of CMS and is housed within HHS. ALJs at OMHA hear Medicare cases at Level 3.

The amount in controversy threshold for Level 3 is updated annually by CMS. Cases below the threshold cannot be heard at Level 3. Multiple claims involving the same beneficiary or the same matter may be aggregated to meet the threshold.

The deadline for filing Level 3 is 60 days from the Level 2 decision. The filing is made with OMHA using forms available on the OMHA website. The beneficiary may have legal representation, family member representation, or proceed pro se.

The hearing process at OMHA has evolved over the past decade. Hearings are typically conducted by telephone or video, with in-person hearings available on request. The hearing is informal compared to federal court litigation: there are no formal rules of evidence, and the ALJ takes a participatory role in developing the record. The beneficiary may present evidence, call witnesses, and cross-examine the contractor's representative.

The ALJ reviews the case de novo, meaning the ALJ may consider new evidence and is not bound by the lower-level decisions. The ALJ applies Medicare coverage rules and issues a written decision, typically within 90 days of the hearing. OMHA had a substantial backlog during the 2010s but has worked to reduce it through various initiatives, and 2025-2026 adjudication is closer to the 90-day target.

The ALJ decision is binding unless the beneficiary or CMS appeals to Level 4.

Level 4: Medicare Appeals Council review

Level 4 is review by the Medicare Appeals Council at the HHS Departmental Appeals Board (DAB at 202-565-0200). The MAC is independent of OMHA and reviews ALJ decisions for legal error, factual support, and procedural regularity.

The deadline for filing Level 4 is 60 days from the ALJ decision. The filing is made with the DAB using forms available on the DAB website.

The MAC review is on the record. The MAC generally does not consider new evidence unless the beneficiary shows good cause for not presenting it at Level 3. The MAC applies the same Medicare coverage rules and may affirm, reverse, or remand the ALJ decision.

The MAC's response time target is 90 days, though backlogs have caused delays at various points. The MAC decision is binding unless the beneficiary appeals to Level 5.

The MAC plays a critical role in Medicare jurisprudence. MAC decisions are published and serve as precedent for similar future cases. Through MAC decisions, the boundaries of Medicare coverage are clarified over time. Lawyers and advocacy organizations rely on MAC decisions to develop case strategies and to advise beneficiaries.

Level 5: federal district court

Level 5 is review by a federal district court under Section 205(g) of the Social Security Act, incorporated by reference into Section 1869 SSA for Medicare. The federal district court for the district where the beneficiary resides has jurisdiction.

For Georgia beneficiaries, the relevant federal courts are:

• Northern District of Georgia (Atlanta area, North Georgia)
• Middle District of Georgia (Macon, Central Georgia)
• Southern District of Georgia (Savannah, Augusta, South Georgia)

The amount in controversy threshold for Level 5 is updated annually by CMS. Cases below the threshold cannot be heard in federal court. Multiple claims may be aggregated to meet the threshold.

The deadline for filing Level 5 is 60 days from the MAC decision. The filing is a civil complaint in the federal district court. Civil filing fees apply, with fee waivers available for low-income beneficiaries.

Federal court review is on the administrative record. The court does not hold new evidentiary hearings. The standard of review is substantial evidence (whether the administrative decision is supported by substantial evidence in the record) and arbitrary and capricious (whether the administrative decision was arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law).

Most federal court Medicare cases are resolved through cross-motions for summary judgment on the administrative record. The court may affirm, reverse, or remand. Successful federal court challenges create precedent for similar cases and may influence CMS regulatory and sub-regulatory guidance.

Federal court review represents the final administrative remedy in Medicare. Beneficiaries who lose at Level 5 may pursue appeal to the federal circuit court of appeals (in Georgia, the Eleventh Circuit) and ultimately to the United States Supreme Court, though Supreme Court review of Medicare appeals is exceedingly rare.

Expedited appeals for urgent matters

Expedited appeals are available at Levels 1 and 2 when the standard timeframe would seriously jeopardize the beneficiary's health or ability to regain maximum function. The expedited framework is one of the most important features of Medicare Advantage and Part D appeals.

The criteria for expedited appeals:

• Beneficiary's health would be seriously jeopardized by waiting for the standard timeframe
• Beneficiary's ability to regain maximum function would be seriously jeopardized
• The request is for a pre-service decision (not a payment decision, which is inherently retrospective and cannot be expedited)

The expedited timelines:

• Plan reconsideration (Level 1, MA and Part D): 72 hours
• IRE reconsideration (Level 2, MA and Part D): 72 hours

To request expedited treatment, the beneficiary or provider must indicate that the request is urgent and explain why. A physician's statement supporting urgency is helpful. The plan or IRE must process the request as expedited if it meets the criteria.

Expedited appeals are not available at Levels 3, 4, and 5 in the same way, though OMHA has expedited procedures for some urgent cases. For most beneficiaries, the practical path for urgent matters is to use the expedited Level 1 and Level 2 processes, which together can produce an independent decision within 6 days for genuinely urgent cases (72 hours plan + 72 hours IRE).

Right to representation

Medicare beneficiaries have the right to be represented at any level of the appeals process. The representative may be:

• An attorney
• A family member
• A friend
• A non-attorney advocate (subject to additional requirements at higher levels)

The appointment of representative is made using form CMS-1696 (Appointment of Representative). The form must be signed by the beneficiary and authorizes the representative to act on the beneficiary's behalf throughout the appeals process. The representative receives copies of all correspondence and may sign filings on behalf of the beneficiary.

Attorney fees for Medicare appeals are regulated under Section 206(a) SSA. Fees are subject to OMHA approval at higher levels. Many beneficiaries with low income receive representation through legal aid organizations on a pro bono basis. In Georgia, the Atlanta Legal Aid Senior Citizens Law Project (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal representation for low-income seniors on Medicare appeals.

The Medicare Rights Center (1-800-333-4114) and the Center for Medicare Advocacy (1-860-456-7790) also provide guidance and limited direct representation in significant cases.

Good cause for late filing

The Medicare appeals process recognizes that beneficiaries sometimes miss filing deadlines for legitimate reasons. Good cause for late filing may be granted in specific circumstances:

• Beneficiary or representative did not understand the appeal procedure
• Death or serious illness in the beneficiary's family
• Destruction of important records by fire or natural disaster
• Reasonable misunderstanding caused by Medicare or the plan
• Other unusual or unavoidable circumstances

To request good cause, the beneficiary submits the late-filed appeal along with an explanation of why the deadline was missed. The reviewer evaluates good cause and may accept or deny the late filing. A denial of good cause is itself appealable.

Good cause provisions reflect the practical reality that beneficiaries dealing with serious illness, family loss, or personal crisis may not be able to meet strict deadlines. The provisions preserve the beneficiary's substantive right to appeal when procedural deadlines have been missed for excusable reasons.

Worked example 1: Margaret 70 Atlanta MA prior auth denial Level 1

Margaret is a 70-year-old retiree living in Atlanta. She is enrolled in a Humana Medicare Advantage HMO plan. Margaret's primary care physician orders a shoulder MRI to evaluate persistent shoulder pain after a fall. Humana denies the prior authorization, citing internal criteria that conservative treatment (physical therapy) should be tried before imaging for non-acute shoulder pain.

Margaret consults with GeorgiaCares (1-866-552-4464) and learns about her appeal rights. The Humana denial notice includes information about filing a Level 1 plan reconsideration. Margaret's physician documents that Margaret already underwent six weeks of physical therapy with limited improvement and that imaging is now clinically appropriate.

Margaret files a Level 1 plan reconsideration with Humana within the 60-day deadline. Under the 2024 Medicare Advantage Final Rule, the plan reconsideration must be reviewed by a physician with appropriate specialty expertise. An orthopedic physician at Humana reviews the case and reverses the denial. Humana approves the MRI prior authorization.

Margaret has the MRI within 3 weeks of the original order. The MRI shows a rotator cuff partial tear. Margaret's physician refers her to an orthopedic surgeon for evaluation.

The case is resolved at Level 1. Margaret did not need to proceed to higher levels because the specialty physician review at Level 1 correctly applied Medicare coverage rules (which under 42 CFR 422.138 require MA plans to use Original Medicare coverage criteria for basic benefits).

Worked example 2: Robert 75 Savannah Original Medicare DME denial Level 2

Robert is a 75-year-old retiree living in Savannah. He has Original Medicare (Part A and Part B). Robert's physician at Memorial Health University Medical Center prescribes a manual wheelchair for Robert, who has limited mobility due to severe osteoarthritis and chronic obstructive pulmonary disease.

The wheelchair supplier submits the claim to Palmetto GBA (the Original Medicare MAC for Georgia DME). Palmetto GBA denies the claim, citing inadequate documentation of medical necessity.

Robert files a Level 1 redetermination with Palmetto GBA within the 120-day deadline. Robert's physician submits additional medical records, including detailed functional assessments documenting Robert's inability to ambulate more than 50 feet without exhaustion. Palmetto GBA upholds the denial after redetermination.

Robert files a Level 2 reconsideration with the QIC, C2C Innovative Solutions (1-866-251-4292), within the 180-day deadline. The QIC reviews the case independently. The QIC reviewer notes that Robert's medical records clearly demonstrate medical necessity under the Medicare wheelchair coverage criteria (limited ambulation, need for mobility within the home, physician's prescription). The QIC reverses the denial.

Palmetto GBA pays the wheelchair supplier. Robert receives his wheelchair within 6 weeks of the QIC decision.

The case was resolved at Level 2 because the independent QIC reviewer correctly applied Medicare coverage rules where the MAC had erred. The QIC's institutional independence and clinical expertise enabled a different outcome than the MAC's review.

Worked example 3: Linda 68 Macon SNF denial through ALJ Level 3

Linda is a 68-year-old retiree living in Macon. She is enrolled in an Aetna Medicare Advantage HMO plan. Linda fractures her hip and undergoes hip replacement surgery at Coliseum Medical Center. Following surgery, her orthopedic surgeon and case manager recommend admission to a skilled nursing facility (SNF) for 20 days of rehabilitation.

Aetna denies the SNF admission, citing internal criteria that Linda can be discharged home with home health services. Linda files a Level 1 plan reconsideration. Aetna upholds the denial after specialty review.

The case is automatically forwarded to the IRE, Maximus Federal Services (1-833-919-0198), at Level 2. Maximus reviews the case but upholds the denial.

Linda's case involves approximately $15,000 in disputed coverage (20 days SNF at $750/day). The amount exceeds the ALJ amount in controversy threshold. Linda files a Level 3 ALJ hearing request through OMHA (1-855-556-8475) within the 60-day deadline.

Linda is represented by an attorney from the Georgia Legal Services Program (1-800-498-9469), which provides free legal representation for low-income Georgians. The ALJ hearing is conducted by video. Linda's attorney presents evidence including her physician's clinical justification, comparative coverage criteria (Original Medicare would cover the SNF under the 3-day qualifying hospital stay rule), and Linda's home situation (she lives alone in a multi-story home and cannot safely manage her recovery at home).

The ALJ rules in Linda's favor, finding that Aetna's denial relied on coverage criteria more restrictive than Original Medicare in violation of 42 CFR 422.138. The ALJ orders Aetna to pay for the SNF stay. Aetna complies with the order.

The case was resolved at Level 3 because the independent ALJ correctly applied Medicare coverage rules where the plan and IRE had erred.

Worked example 4: Charles 73 Augusta Part D drug expedited 72-hour appeal

Charles is a 73-year-old retiree living in Augusta. He is enrolled in a Cigna Part D plan. Charles has atrial fibrillation and is prescribed apixaban (brand-name Eliquis) by his cardiologist. The cardiologist documents that Charles has tried other anticoagulants and experienced adverse effects, making Eliquis the most clinically appropriate option.

Cigna's Part D formulary requires prior authorization for Eliquis. Charles's cardiologist submits the prior authorization request. Cigna denies the prior authorization, citing internal step therapy criteria requiring trial of generic alternatives first.

Charles's cardiologist files an expedited Level 1 plan reconsideration with Cigna, indicating urgency because Charles is at high stroke risk and needs anticoagulation without delay. The expedited 72-hour timeline applies. Cigna's reviewer upholds the denial.

The case is forwarded to the IRE, Maximus Federal Services, at Level 2 with expedited treatment. Maximus reviews within the 72-hour expedited window. The Maximus reviewer notes that Charles has documented adverse reactions to alternatives and that the cardiologist's clinical judgment is supported by widely accepted clinical evidence. Maximus reverses the denial.

Cigna covers Eliquis at the formulary cost-sharing tier. Charles fills his Eliquis prescription within 6 days of the original denial.

The case was resolved at Level 2 through the expedited 72-hour processes at both Level 1 and Level 2. The expedited framework prevented a dangerous delay in anticoagulation therapy.

Worked example 5: Patricia 65 Columbus MAC Level 4 reversal

Patricia is a 65-year-old new Medicare beneficiary living in Columbus. She enrolled in a UnitedHealthcare Medicare Advantage HMO plan effective her 65th birthday. Three months into her enrollment, Patricia is diagnosed with metastatic colorectal cancer. Her oncologist at the Piedmont Columbus Regional cancer center recommends a treatment regimen that includes an off-label use of an FDA-approved drug. The off-label use is supported by widely accepted clinical evidence (peer-reviewed studies, NCCN treatment guidelines) but is not within the FDA-approved indications.

UnitedHealthcare denies coverage, citing the off-label indication. Patricia files a Level 1 plan reconsideration. UnitedHealthcare upholds the denial after specialty oncology review at the plan level.

The case is forwarded to the IRE, Maximus Federal Services, at Level 2. Maximus upholds the denial, concluding that the off-label use is not within the FDA-approved indications and the plan is not required to cover off-label use absent specific compendia support.

Patricia's amount in controversy is approximately $60,000 for the planned course of treatment. She files a Level 3 ALJ hearing request through OMHA. Patricia is represented by an attorney from the Atlanta Legal Aid Senior Citizens Law Project (404-377-0701), which provides free representation for low-income seniors. The ALJ hears the case by video. The ALJ rules against Patricia, finding that the off-label use is not adequately supported under the relevant Medicare drug coverage compendia.

Patricia files a Level 4 MAC review with the DAB (202-565-0200) within the 60-day deadline. Her attorney prepares a detailed brief documenting that the off-label use is supported by NCCN compendia (one of the compendia recognized under Medicare drug coverage rules). The MAC reviews the case on the record.

The MAC reverses the ALJ, finding that the ALJ failed to properly consider the NCCN compendia support for the off-label use. The MAC orders UnitedHealthcare to cover the treatment. UnitedHealthcare complies.

The case was resolved at Level 4 because the MAC correctly applied Medicare drug coverage rules where the ALJ had erred. The MAC's role as an independent reviewer of ALJ decisions is critical for ensuring legal consistency.

Worked example 6: Henry 72 Athens federal district court Level 5

Henry is a 72-year-old retiree living in Athens. He is enrolled in an Anthem Blue Cross Blue Shield Medicare Advantage HMO plan. Henry has a rare inherited metabolic disorder requiring a specialty drug that costs approximately $50,000 per year. Henry's specialist at Emory Healthcare in Atlanta prescribes the drug, citing that it is the only effective treatment available.

Anthem denies coverage, citing internal coverage criteria that classify the drug as experimental for Henry's specific subtype of the metabolic disorder. Henry's specialist submits clinical evidence that the drug has been used effectively for the broader category of the disorder and is the standard of care for similar cases.

Henry pursues all four administrative levels:

• Level 1 plan reconsideration: Anthem upholds the denial
• Level 2 IRE reconsideration: Maximus upholds the denial
• Level 3 ALJ hearing: ALJ upholds the denial, citing the experimental classification
• Level 4 MAC review: MAC affirms the ALJ on the record

Henry's amount in controversy ($50,000) far exceeds the federal court amount in controversy threshold. Within the 60-day deadline after the MAC decision, Henry's attorney files a civil complaint in the Northern District of Georgia (Athens is within the Northern District).

The court reviews the administrative record. Henry's attorney argues that the administrative decision was arbitrary and capricious because it ignored the clinical evidence and applied an unduly narrow definition of "experimental." Anthem's attorney argues that the administrative decision was supported by substantial evidence.

The court reverses the MAC, finding that the administrative decision was arbitrary and capricious. The court orders Anthem to cover the drug for Henry. Anthem complies with the federal court order.

The case was resolved at Level 5 because the federal court correctly applied the substantial evidence and arbitrary and capricious standards. The case becomes precedent for similar cases involving the same drug and the same condition.

Common mistakes Georgia beneficiaries make

Many Georgia Medicare beneficiaries make avoidable mistakes when pursuing appeals. Understanding the rules helps avoid these mistakes.

The first mistake is missing the filing deadline. Original Medicare allows 120 days for Level 1 redetermination, but Medicare Advantage and Part D allow only 60 days for Level 1 plan reconsideration. Beneficiaries who assume the longer Original Medicare deadline applies to their MA plan often miss the MA deadline.

The second mistake is not requesting expedited appeal when health is at risk. The 72-hour expedited timeline at Levels 1 and 2 in Medicare Advantage and Part D is one of the most important consumer protections. Beneficiaries facing urgent matters should request expedited treatment.

The third mistake is filing the wrong level. Beneficiaries must start at Level 1 and proceed through the levels in order. The appeals process does not allow skipping levels (with limited exceptions for procedural defects).

The fourth mistake is not preserving evidence. Medical records, physician statements, and billing records are critical at every level. Beneficiaries should collect and organize records as soon as they receive an adverse determination.

The fifth mistake is not knowing about Maximus Federal Services (1-833-919-0198) as the Medicare Advantage and Part D IRE. Some beneficiaries do not realize the case is automatically forwarded to Maximus after Level 1 in MA plans.

The sixth mistake is not requesting specialty physician review at Level 1. Under the 2024 CMS final rule, MA plans must use specialty physicians to review clinical denials. Beneficiaries can explicitly request that the reviewer be a physician with appropriate specialty expertise.

The seventh mistake is not contacting GeorgiaCares (1-866-552-4464). The State Health Insurance Assistance Program provides free unbiased counseling on Medicare appeals. GeorgiaCares counselors are trained on the current appeals rules and can help with forms, deadlines, and evidence.

The eighth mistake is assuming federal court is the only option. The vast majority of Medicare appeals are resolved at Levels 1 and 2. Beneficiaries should pursue the lower levels first and consider higher levels only if needed.

The ninth mistake is not aggregating claims to meet thresholds. The ALJ and federal court amount in controversy thresholds can be met by aggregating multiple claims for the same beneficiary or matter.

The tenth mistake is giving up after a Level 1 denial. Government oversight data shows that a substantial proportion of appealed MA prior authorization denials are ultimately reversed. Persistence through the appeals process pays off.

When state-level remedies are available

The Medicare appeals process is a federal process. State courts and state agencies generally do not have jurisdiction over Medicare coverage determinations. However, some state-level remedies are available for related matters.

The Georgia Office of Insurance Commissioner (1-800-656-2298) oversees consumer protection for insurance generally. While the Insurance Commissioner cannot directly reverse a Medicare coverage determination, the office can investigate complaints about plan practices, including marketing violations, billing practices, and patterns of inappropriate denial. The Insurance Commissioner can pressure plans to comply with federal and state requirements.

The Georgia Attorney General's Office Consumer Protection Division can investigate patterns of consumer harm. If a Medicare Advantage plan engages in systematic deception or fraud, the Attorney General may bring action under Georgia consumer protection laws.

The Medicare Beneficiary Ombudsman (accessible through 1-800-MEDICARE) is a federal advocate within CMS that helps beneficiaries navigate the Medicare program. The Ombudsman cannot reverse coverage determinations but can advocate for beneficiaries in their dealings with plans, contractors, and CMS.

For dual-eligible beneficiaries (Medicare + Medicaid), additional remedies are available through the Georgia Department of Community Health Medicaid program. Medicaid appeals are separate from Medicare appeals and follow different procedures. Coordination between the two programs is important for dual-eligible beneficiaries.

How Brevy supports Georgia Medicare beneficiaries

Brevy (brevy.com) provides comprehensive Medicare and Medicaid resources for Georgia families. Our state-by-state guides cover Medicare appeals, prior authorization, drug pricing, vaccines, and many other topics. We update our content as federal and state rules evolve. Our goal is to be the most trustworthy and up-to-date eldercare resource for American families. For free unbiased counseling on a specific case, contact GeorgiaCares (SHIP) at 1-866-552-4464.

::: accordion Frequently asked questions about Georgia Medicare appeals process

What is the Medicare appeals process?

The Medicare appeals process is the federal framework that allows Medicare beneficiaries to challenge an adverse coverage determination. Under Section 1869 of the Social Security Act (Original Medicare), Section 1852(g) (Medicare Advantage), and Section 1860D-4(g) (Part D), every Medicare beneficiary has the right to appeal through a five-level structure: plan reconsideration or redetermination, Independent Review Entity or Qualified Independent Contractor reconsideration, ALJ hearing through OMHA, Medicare Appeals Council review, and federal district court.

How many levels of appeal are there?

There are five levels of Medicare appeal. Level 1: plan reconsideration (MA, Part D) or redetermination (Original Medicare). Level 2: IRE reconsideration (MA, Part D) or QIC reconsideration (Original Medicare). Level 3: ALJ hearing. Level 4: Medicare Appeals Council review. Level 5: federal district court.

How long do I have to file an appeal?

Original Medicare: 120 days to file Level 1 redetermination from the initial determination. Medicare Advantage and Part D: 60 days to file Level 1 plan reconsideration from the denial notice. Levels 2 through 5: generally 60 days from the prior level's decision (with Original Medicare Level 2 having 180 days to file with the QIC).

What is the amount in controversy threshold for an ALJ hearing?

The amount in controversy threshold for an ALJ hearing (Level 3) is updated annually by CMS. Check CMS.gov for the current year threshold. Multiple claims involving the same beneficiary may be aggregated to meet the threshold.

What is the amount in controversy threshold for federal district court?

The amount in controversy threshold for federal district court review (Level 5) is updated annually by CMS and is set higher than the ALJ threshold. Check CMS.gov for the current year threshold. Multiple claims involving the same beneficiary may be aggregated.

Who is Maximus Federal Services?

Maximus Federal Services is the Independent Review Entity (IRE) for Medicare Advantage and Part D. Maximus reviews appeals at Level 2 independently of the Medicare Advantage plan or Part D plan. Phone: 1-833-919-0198.

Who is C2C Innovative Solutions?

C2C Innovative Solutions is the Qualified Independent Contractor (QIC) for Original Medicare Parts A and B. C2C reviews appeals at Level 2 independently of the MAC (Palmetto GBA for Georgia). Phone: 1-866-251-4292.

What is OMHA?

OMHA (Office of Medicare Hearings and Appeals) is the HHS agency that hosts the Administrative Law Judges who hear Medicare appeals at Level 3. OMHA is independent of CMS. Phone: 1-855-556-8475.

What is the Medicare Appeals Council?

The Medicare Appeals Council (MAC) is part of the HHS Departmental Appeals Board (DAB). The MAC reviews ALJ decisions at Level 4. Phone: 202-565-0200.

Can I request an expedited appeal?

Yes. Expedited appeals are available at Levels 1 and 2 in Medicare Advantage and Part D when waiting for the standard timeframe would seriously jeopardize the beneficiary's health or ability to regain maximum function. The expedited timeline is 72 hours at each level.

What if I miss the filing deadline?

You may request good cause for late filing. Good cause may be granted for: lack of understanding of the appeal procedure, death or serious illness in the family, destruction of records by fire or natural disaster, reasonable misunderstanding caused by Medicare or the plan, or other unusual circumstances. Submit the late-filed appeal with an explanation; the reviewer evaluates good cause.

Can I have representation in my Medicare appeal?

Yes. You may be represented by an attorney, family member, friend, or non-attorney representative. The appointment of representative is made using form CMS-1696. Free legal representation is available in Georgia through Atlanta Legal Aid (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) for low-income beneficiaries.

Where can I get free help with a Medicare appeal in Georgia?

GeorgiaCares (1-866-552-4464) is Georgia's State Health Insurance Assistance Program (SHIP) and provides free unbiased counseling on Medicare appeals. Medicare Rights Center (1-800-333-4114) and Center for Medicare Advocacy (1-860-456-7790) also provide assistance.

Are Medicare Advantage prior authorization denials often reversed on appeal?

Government oversight reports have found that a substantial proportion of Medicare Advantage prior authorization denials appealed by enrollees are ultimately reversed in favor of the beneficiary. The reversal rate suggests that many initial denials are issued in error or based on overly restrictive plan criteria. If your claim was denied, pursuing the appeals process is worthwhile.

What is the difference between a redetermination and a plan reconsideration?

A redetermination is the Level 1 appeal in Original Medicare, conducted by the Medicare Administrative Contractor (Palmetto GBA for Georgia). A plan reconsideration is the Level 1 appeal in Medicare Advantage and Part D, conducted by the plan itself. Both are the first step in the appeals process for their respective programs.

How long does Level 1 take?

Original Medicare redetermination: 60 days. Medicare Advantage plan reconsideration: 30 days for standard pre-service, 60 days for payment, 72 hours for expedited. Part D plan reconsideration: 7 days for standard, 72 hours for expedited.

How long does Level 2 take?

Original Medicare QIC reconsideration: 60 days. Medicare Advantage IRE reconsideration: 30 days for standard, 72 hours for expedited. Part D IRE reconsideration: 7 days for standard, 72 hours for expedited.

How long does Level 3 ALJ hearing take?

OMHA's target adjudication time is 90 days from the request. Actual times have varied due to backlogs but in 2025-2026 are closer to the 90-day target.

How long does Level 4 MAC review take?

The Medicare Appeals Council's target adjudication time is 90 days from the request. Actual times have varied due to backlogs.

What standard does federal court use to review Medicare appeals?

Federal court review is on the administrative record and uses the substantial evidence standard (whether the administrative decision is supported by substantial evidence in the record) and the arbitrary and capricious standard (whether the decision was arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law).

Can I appeal a Medicare appeal denial to the Supreme Court?

Theoretically, yes. After federal district court, the beneficiary may appeal to the federal circuit court of appeals (Eleventh Circuit for Georgia) and ultimately to the United States Supreme Court. In practice, Supreme Court review of Medicare appeals is exceedingly rare; the Court grants certiorari in only a handful of Medicare cases each decade.

Does Original Medicare or Medicare Advantage have a better appeals process?

Both programs have the same five-level structure under federal law. Original Medicare has longer filing deadlines at Level 1 (120 days vs. 60 days for MA). Medicare Advantage has more frequent prior authorization, more frequent appeals, and higher denial rates than Original Medicare. The appeals process protects beneficiaries in both programs but is used more often in Medicare Advantage due to the higher denial rate.

Can a state agency reverse a Medicare denial?

No. Medicare is a federal program, and Medicare coverage determinations can only be reversed through the federal appeals process. State agencies including the Georgia Office of Insurance Commissioner can investigate plan practices and pressure plans to comply with federal requirements but cannot directly reverse a Medicare coverage decision.

What if I am dually eligible for Medicare and Medicaid?

Dual-eligible beneficiaries may have appeals available under both Medicare and Medicaid. Medicare appeals follow the federal process described in this guide. Medicaid appeals follow Georgia Medicaid procedures through the Georgia Department of Community Health. Coordination between the two programs is important; GeorgiaCares (1-866-552-4464) and Georgia Legal Services Program (1-800-498-9469) can help with coordination.

What if my appeal involves Medicare improper billing or scams?

Improper billing by providers and Medicare scams are separate from coverage appeals. Improper billing should be reported to the Medicare Beneficiary Ombudsman (through 1-800-MEDICARE) and the HHS Office of Inspector General (1-800-HHS-TIPS). Medicare scams should be reported to the Georgia Senior Medicare Patrol (administered through GeorgiaCares at 1-866-552-4464). :::

::: cta Get help with Medicare appeals in Georgia

• DCH Medicaid Member Services 1-866-211-0950
• Medicare 1-800-MEDICARE (1-800-633-4227)
• GeorgiaCares (SHIP) 1-866-552-4464
• Maximus Federal Services (MA and Part D IRE) 1-833-919-0198
• C2C Innovative Solutions (Original Medicare Part A/B QIC) 1-866-251-4292
• OMHA (Office of Medicare Hearings and Appeals) 1-855-556-8475
• DAB Medicare Appeals Council 202-565-0200
• Palmetto GBA Georgia MAC 1-855-696-0705
• Medicare Rights Center 1-800-333-4114
• Center for Medicare Advocacy 1-860-456-7790
• Justice in Aging 202-289-6976
• Atlanta Legal Aid Senior Citizens Law Project 404-377-0701
• Georgia Legal Services Program 1-800-498-9469
• Medicare Beneficiary Ombudsman: contact through 1-800-MEDICARE
• Georgia Office of Insurance Commissioner 1-800-656-2298
• Social Security Administration 1-800-772-1213
• AARP Georgia 1-866-295-7283
• Eldercare Locator 1-800-677-1116 :::

Find personalized help navigating Georgia Medicare appeals at brevy.com.

This guide is provided by Brevy (brevy.com) as a public education resource. It does not constitute legal, medical, or financial advice. Medicare rules and regulations change frequently. Filing deadlines and amount in controversy thresholds change annually. For specific guidance on your situation, consult the agencies and organizations listed above, including GeorgiaCares (1-866-552-4464) for free unbiased counseling, or speak with a licensed Medicare attorney. Last verified May 13, 2026.