42 CFR 422 Subpart M
The Medicare Advantage appeal track. MA enrollees have FIVE levels of appeal (vs the 2 levels typical of commercial plans) and significantly tighter deadlines, especially for expedited cases.
What 42 CFR 422 Subpart M does
42 CFR Part 422 Subpart M establishes the grievance + organization determination + reconsideration framework for Medicare Advantage. The five appeal levels are: (1) Reconsideration by the MA plan, (2) Reconsideration by an Independent Review Entity (IRE) — currently Maximus Federal Services, (3) Hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA), (4) Review by the Medicare Appeals Council, (5) Judicial review in federal district court. Reconsideration deadlines are tight: standard 30 days, expedited 72 hours.
When to invoke it
Cite Subpart M on every Medicare Advantage denial — both at level 1 (plan-level reconsideration) and especially when escalating to the IRE at level 2. The expedited 72-hour timeline is particularly powerful: any time the enrollee's life, health, or function would be jeopardised by waiting 30 days, the plan MUST expedite (42 CFR §422.570).
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Time to request reconsideration | 60 days from notice of denial |
| Standard reconsideration decision | 30 days (pre-service) / 60 days (post-service) |
| Expedited reconsideration decision | 72 hours |
| IRE auto-forward (if plan misses deadline) | Automatic — plan must forward case to IRE |
| ALJ hearing amount-in-controversy threshold (2024) | $180 (lower than other Medicare tracks) |
Plans this applies to
- Medicare Advantage plans (Part C)
- Medicare Advantage Prescription Drug plans (MAPD)
Frequently asked questions
What does 42 CFR 422 Subpart M require?
42 CFR Part 422 Subpart M establishes the grievance + organization determination + reconsideration framework for Medicare Advantage. The five appeal levels are: (1) Reconsideration by the MA plan, (2) Reconsideration by an Independent Review Entity (IRE) — currently Maximus Federal Services, (3) Hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA), (4) Review by the Medicare Appeals Council, (5) Judicial review in federal district court. Reconsideration deadlines are tight: standard 30 days, expedited 72 hours.
When do I cite 42 CFR 422 Subpart M in an appeal?
Cite Subpart M on every Medicare Advantage denial — both at level 1 (plan-level reconsideration) and especially when escalating to the IRE at level 2. The expedited 72-hour timeline is particularly powerful: any time the enrollee's life, health, or function would be jeopardised by waiting 30 days, the plan MUST expedite (42 CFR §422.570).
What are the key deadlines under 42 CFR 422 Subpart M?
Time to request reconsideration: 60 days from notice of denial. Standard reconsideration decision: 30 days (pre-service) / 60 days (post-service). Expedited reconsideration decision: 72 hours. IRE auto-forward (if plan misses deadline): Automatic — plan must forward case to IRE. ALJ hearing amount-in-controversy threshold (2024): $180 (lower than other Medicare tracks)
Which plans does 42 CFR 422 Subpart M apply to?
Medicare Advantage plans (Part C); Medicare Advantage Prescription Drug plans (MAPD).
Related
- CARC 50Common denial code where 42 CFR 422 Subpart M applies.
- CARC 55Common denial code where 42 CFR 422 Subpart M applies.
- CARC 96Common denial code where 42 CFR 422 Subpart M applies.
- CARC 197Common denial code where 42 CFR 422 Subpart M applies.
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Sources
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