Which Appeal Rules Apply?
Which coverage-request and appeal rules apply to a plan and item.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Coverage type
- Medicare Advantage
- What is being requested
- A drug on the medical benefit (given in a clinic or infusion center)
Result: Medicare Advantage organization determination and appeal rules (42 CFR 422 subpart M). A decision within 7 days for prior authorization, 14 days otherwise, 72 hours for a Part B drug; after a denial, a reconsideration request within 60 days of receiving the notice (42 CFR 422.582).
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Coverage type
- What is being requested
How this is calculated
Citation
42 CFR 423 subpart M (Part D), 422 subpart M (Medicare Advantage), 405 subpart I (Original Medicare), 438 subpart F and 431 subpart E (Medicaid), 29 CFR 2560.503-1 (employer plans) and 45 CFR 147.136 (internal appeals and external review). Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.