In Medicare Advantage, appeals and grievances are separate processes. An appeal challenges a plan's decision about coverage or payment for a service, called an organization determination. A grievance is any other complaint about how the plan or a provider behaves, such as trouble reaching the plan by phone or rude staff. Each has its own deadlines, reviewers and outcomes.
Medicare Advantage appeals versus grievances
A Medicare Advantage appeal disputes an organization determination: a plan's decision to deny, reduce or delay a service or a payment. A grievance is any other complaint about the plan's or a provider's operations, activities or behavior. The federal rules in 42 CFR Part 422, Subpart M set out both.
The definitions are exact. Under 42 CFR 422.561, a grievance is "any complaint or dispute, other than one that constitutes an organization determination, expressing dissatisfaction with any aspect of an MA organization's or provider's operations, activities, or behavior, regardless of whether remedial action is requested." An appeal is any of the procedures that review an adverse organization determination.
So the test is the subject of the complaint, not its tone. Under 42 CFR 422.566, organization determinations include a plan's refusal to provide or pay for services in whole or in part, a reduction or early end to an authorized course of treatment, and a failure to approve or pay in a timely way when the delay would harm the enrollee's health. Anything that disputes one of those decisions is an appeal.
The CMS Parts C and D enrollee grievances, organization/coverage determinations, and appeals guidance lists examples of grievances. They include difficulty reaching the plan by phone, interpersonal aspects of care, the plan's decision not to expedite a request, and general dissatisfaction with a copayment amount, as long as the enrollee is not disputing the amount actually paid or billed. The same guidance says an enrollee does not need to use any specific words, and the plan must decide which category applies and tell the enrollee.
Appeals and grievances side by side
This comparison summarizes the rules from Subpart M for standard, non-drug cases.
| Appeal (reconsideration) | Grievance | |
|---|---|---|
| Trigger | An adverse organization determination: a denied, reduced or delayed service or payment | Any other complaint about the plan's or a provider's operations, activities or behavior |
| Filing deadline | 60 calendar days after receipt of the written determination notice | 60 days after the event or incident |
| How to file | In writing, unless the plan accepts oral requests | Orally or in writing |
| Plan's decision deadline | 30 calendar days for a service, 60 for a payment, 7 for a Part B drug; 72 hours if expedited | 30 days, extendable by up to 14 days; 24 hours for certain expedited grievances |
| Reviewer | Someone not involved in the original decision; a physician when the issue is medical necessity | The plan's grievance process |
| Outcome if unresolved | An adverse decision goes automatically to an independent review entity, then onward to higher levels | A written or oral disposition; no further appeal levels |
One complaint can contain both. If a patient calls about a denied MRI and also about being kept on hold for an hour, the guidance says each issue should be processed separately under the right procedure.
The Medicare Advantage appeals process step by step
The Medicare Advantage appeals process starts with a reconsideration by the plan itself. If the plan upholds its denial, in whole or in part, the case goes automatically to an independent review entity under contract with CMS. After that come an administrative law judge hearing, Medicare Appeals Council review and federal district court, each with conditions.
The steps, with the rules that govern each:
- Organization determination. The plan decides. For a service not subject to prior authorization rules, 42 CFR 422.568 gives the plan 14 calendar days; for a service subject to those rules, starting January 1, 2026, it gives 7. A denial must come with a written notice stating the specific reasons and the right to a reconsideration.
- Plan reconsideration. Under 42 CFR 422.582, the request must be filed within 60 calendar days after receipt of the written notice, and receipt is presumed to be 5 calendar days after the notice date unless there is evidence otherwise. A late request can be accepted for good cause.
- Plan decision. Under 42 CFR 422.590, the plan has 30 calendar days for a service, 60 for a payment and 7 for a Part B drug. An expedited reconsideration must be decided within 72 hours. If the plan misses its deadline, that counts as an affirmation of the denial and the file goes forward anyway.
- Independent review entity. When the plan affirms its denial in whole or in part, 42 CFR 422.592 requires the issues to be reviewed by an independent outside entity that contracts with CMS. No one has to ask: the plan forwards the case file itself.
- Administrative law judge. Under 42 CFR 422.602, a party has 60 calendar days from receipt of the independent entity's decision to request a hearing, provided the amount in controversy meets a threshold the Secretary sets each year.
- Medicare Appeals Council, then federal court. Under 42 CFR 422.608, any party, including the plan, can ask the Council to review the hearing decision. Under 42 CFR 422.612, judicial review also requires the amount in controversy to meet the annual threshold.
A fictional timeline
Every name and number here is made up. A plan denies payment for a claim for a fictional patient, Rosa Delgado, member ID EX123456789, claim number EX-2026-004471. The written denial is dated March 3. Receipt is presumed on March 8, so a reconsideration request is due by May 7. The plan receives the request on April 20. Because it is a payment request, the plan must decide by June 19. If it upholds the denial, it sends the file to the independent review entity without waiting to be asked.
The levels of Original Medicare appeals work differently, with different contractors and forms. They are covered in the guide to the five Medicare appeal levels and the form for each.
How are Medicare Advantage grievances filed and answered?
A Medicare Advantage grievance can be filed orally or in writing, no later than 60 days after the event that caused it. The plan must answer as quickly as the enrollee's health requires, and no later than 30 days after it receives the grievance. It can extend that by up to 14 days in limited cases.
The details come from 42 CFR 422.564. The plan may extend the 30 days only if the enrollee asks, or if the plan justifies a need for more information and documents how the delay helps the enrollee. When it extends, it must tell the enrollee in writing why, straight away.
How the answer arrives depends on how the grievance came in:
- A written grievance gets a written response.
- An oral grievance can get an oral or written response, unless the enrollee asks for it in writing.
- A grievance about quality of care always gets a written response, and that response must describe the enrollee's right to complain to the Quality Improvement Organization (QIO).
Some grievances must be answered within 24 hours. The regulation names two: a complaint about the plan's decision to take an extension on an organization determination or reconsideration, and a complaint about the plan's refusal to expedite one. A provider's office that asked for a fast decision and was turned down can help the patient file the second kind.
Plans must also keep records. Each grievance, oral or written, must be tracked with at least the date it was received, the final disposition and the date the enrollee was told. For a practice, that means a grievance filed on a patient's behalf should be logged on your side too, with the date and the person the office spoke to, so you can follow up when the 30 days run out.
Can providers file Medicare Advantage appeals for a patient?
Providers can take part in Medicare Advantage appeals in three ways. A treating physician can request a standard pre-service reconsideration for the patient after notifying them. Any physician can request an expedited one. A non-contract provider can appeal its own denied claim by signing a waiver of liability. Otherwise, the provider needs to be the patient's appointed representative.
The rules for each route:
- Treating physician, pre-service. 42 CFR 422.578 lets a physician who is treating the enrollee, upon providing notice to the enrollee, request a standard reconsideration of a pre-service request on their behalf. The CMS guidance adds that office staff can file on the physician's behalf when the request is on the physician's letterhead or otherwise shows it is under the physician's direction.
- Expedited requests. An enrollee or a physician acting for them may request an expedited reconsideration.
- Non-contract provider, payment. The CMS guidance says a non-contract provider may request a reconsideration of a denied claim on its own behalf only if it completes a waiver of liability statement, promising not to bill the enrollee whatever the outcome. With a valid waiver on file, the provider does not need a representative form, and the plan's correspondence goes to the provider.
- Appointed representative. For anything else, including filing a grievance for a patient, the provider acts as the patient's representative. The guidance says the enrollee must submit Form CMS-1696, Appointment of Representative, or an equivalent written notice, and plans must accept either.
The representative form has its own rules. According to the guidance, it is valid for one year from the date both the enrollee and the appointee have signed it, unless revoked. An enrollee cannot appoint a representative by phone. If a purported representative calls and the enrollee confirms the request on the line, the plan processes it as the enrollee's own request, and correspondence goes to the enrollee until a written form is on file.
For billing offices, the practical step is to check the appointment before filing: is there a signed form under a year old, or does this request fall under the physician or waiver routes? Whether that work sits with your own staff or an outside company is one of the questions in the guide to in house vs outsourced medical billing. Many payment appeals begin with a code on a remittance; Schema Care turns EOB service lines and remark codes into fields and routes any it is unsure of to a reviewer, which the list of documents Schema Care reads describes.
Medicare Advantage disputes that fit neither appeals nor grievances
Some Medicare Advantage disputes fit neither process. The largest group is payment disputes between a plan and a contracted provider when the patient owes nothing more. Quality-of-care complaints can also go to a separate body, the Quality Improvement Organization, instead of or as well as the plan.
Contract provider payment disputes are excluded by rule. 42 CFR 422.562 says that if a contract provider's request for payment has been adjudicated and the enrollee has no further liability to pay, the claim payment determination is not subject to the Subpart M appeal process. The CMS guidance puts it plainly: no party may appeal a contract provider payment denial when the enrollee has no further financial liability, and those disputes are governed by the dispute resolution provisions in the contract between the provider and the plan.
That has a direct effect on a practice's workflow. A denied or underpaid claim from a plan you contract with usually goes through the plan's provider dispute process, on the timelines your contract sets, not through a reconsideration request. Filing a Subpart M appeal for it wastes time and can let the contract's own deadline pass. Read the dispute section of each Medicare Advantage contract and record its deadlines next to the payer in your billing system.
Quality complaints are the second case. Under 42 CFR 422.564, the QIO must review beneficiaries' written complaints about the quality of Medicare services, and that process is separate from the plan's grievance procedure. An enrollee may use either or both, and the plan must cooperate with the QIO.
A third, quieter case is the misfiled request. The CMS guidance says that if a plan misclassifies a grievance as an appeal and the case reaches the independent review entity, the entity dismisses it and returns it to the plan for the grievance process. Classifying correctly at the start avoids weeks of delay.
Unresolved plan disputes tend to sit in the oldest aging buckets. The guide to splitting AR aging by payer and cause shows how to find them. Supporting records for appeals often arrive by fax, and the medical faxes and referrals category covers how those pages get sorted and filed.
This post describes what the regulations and CMS guidance say. It is not legal advice, and a plan's own notice controls the details of any specific case.