Federal programs

• Original Medicare (Parts A and B) →

  Five levels. Level 1 is a redetermination by the Medicare Administrative Contractor named on your Medicare Summary Notice; level 2 is a reconsideration by a Qualified Independent Contractor.

• Medicare Advantage (Part C) →

  Plans use their own reconsideration form, but none is required: a signed written request with the enrollee's name, Medicare number and the service denied is enough. If the plan upholds the denial it must send the case to the Independent Review Entity itself.

• Medicare Part D (drug coverage) →

  A coverage determination first (including exceptions, which need the prescriber's supporting statement), then a redetermination by the plan, then the Independent Review Entity.

• Federal external review (HHS-administered states and self-funded employer plans) →

  Where a state has no external review process, or for self-funded employer plans, the federal process applies: an accredited independent review organization, requested within four months of the final internal denial.

• TRICARE →

  Reconsideration by the regional contractor first (Humana Military in the East, TriWest in the West), then formal review by the Defense Health Agency, then a hearing above the amount-in-controversy threshold.