Medicare Advantage appeals for behavioral health

How does a Medicare Advantage appeal start?

With the plan's organization determination, its initial decision on a service or payment. The enrollee or any provider that furnishes or intends to furnish the service can request one. A denial notice must state the specific reasons and explain reconsideration rights, and a plan that fails to give timely notice has made an adverse decision that can be appealed.

Since January 1, 2026, standard decisions on items and services subject to the plan's prior authorization rules are due within 7 calendar days, and expedited decisions within 72 hours. Other standard requests still have 14 days. A physician or other appropriate professional must review a medical-necessity denial before it issues.

What is the deadline for a Medicare Advantage reconsideration?

Sixty calendar days after receiving the written denial, which the regulation presumes arrives 5 days after the notice date. CMS and Medicare.gov therefore state the window as 65 calendar days from the date on the notice. The plan can accept a late request for good cause. Work to the 65-day date and file early.

A treating physician may request a standard pre-service reconsideration for the enrollee after notifying the enrollee, and may request an expedited one. Payment appeals by contracted providers follow different rules, explained below.

When must a Medicare Advantage plan expedite a reconsideration?

When applying the standard timeframe could seriously jeopardize the enrollee's life or health or ability to regain maximum function. If a physician requests or supports the request and says so, the plan must expedite. An expedited reconsideration is decided as quickly as the enrollee's condition requires and no later than 72 hours.

Expedited and standard service reconsiderations can be extended by up to 14 days in limited cases; Part B drug reconsiderations cannot. For a patient still in a psychiatric unit or partial program, prepare the expedited continued-stay appeal and have the physician's support documented.

What happens at the independent review entity?

If the plan upholds its denial in whole or in part, it must send the case file to the independent review entity automatically; the enrollee does not file anything. A plan that misses its reconsideration deadline is treated as upholding the denial and must forward the case too. Since May 1, 2026, the Part C entity is C2C Innovative Solutions.

Maximus Federal Services, the previous contractor, still processes requests it received through April 30, 2026. After the independent review, the enrollee can ask for a hearing before an administrative law judge or attorney adjudicator within 60 days, if at least $200 is in dispute in 2026, then the Medicare Appeals Council and federal court, which needs $1,960 in dispute in 2026.

How do contracted and non-contracted providers appeal?

Contracted providers generally cannot use the enrollee appeal process for payment denials when the enrollee owes nothing more; those disputes follow the plan contract. Non-contracted providers can appeal a payment denial in their own name if they sign a waiver of liability promising not to bill the enrollee, within 65 days of the remittance.

Clinical disputes about services the enrollee still needs are different: a treating physician can request a pre-service reconsideration for the enrollee. Check your contract for the plan's provider dispute process before choosing a route.

What about inpatient psychiatric discharges?

Inpatient hospital discharges have a separate fast track. When a Medicare Advantage plan or hospital, with physician concurrence, decides inpatient care is no longer necessary, the enrollee can request an immediate review by the Quality Improvement Organization, no later than the day of discharge, in writing or by phone. The hospital's notice explains how.

A timely request for immediate review carries financial-liability protections set out in the regulation. An enrollee who misses the deadline can still ask the plan for an expedited reconsideration, but those protections then do not apply, so make sure the enrollee or representative knows the deadline.

Which criteria can a Medicare Advantage plan use for behavioral health?

Medicare Advantage plans must follow Medicare's own coverage rules, including national and local coverage determinations. They may create internal coverage criteria only where Medicare's criteria are not fully established, and those criteria must be publicly accessible and based on widely used treatment guidelines or strong clinical literature.

That is why payer manuals name CMS criteria for Medicare members: Carelon applies CMS coverage criteria first, and Aetna uses CMS criteria for Medicare Advantage organization determinations. If a denial cites a proprietary guideline, ask the plan to identify the Medicare rule it supplements and where its criteria are published.

Which denial codes come up on Medicare Advantage behavioral health claims?

Medicare Advantage remittances use the standard reason codes. Medical necessity (50) and denial at authorization (39) lead to reconsideration; precertification absent (197) depends on whether the plan required it; timely filing (29), provider type (170) and rendering-provider eligibility (185) usually need records or enrollment fixes rather than a clinical argument.