In this guide 5 sections
A Medicare Advantage plan has denied prior authorization for a scan. When the plan upholds all or part of an adverse decision after reconsideration, it must send the case file and a written explanation to the CMS contracted independent entity.
What is an IRE?
An IRE is an independent, outside organization that contracts with the Centers for Medicare and Medicaid Services. It reviews and resolves disputed issues in Medicare Advantage cases.
What does the IRE do?
The independent entity reviews and resolves the disputed issues. Its review is independent of the Medicare Advantage plan.
What should happen next?
- 1.Ask the plan to confirm the date it sent the case file to the IRE.
- 2.Ask what records and written explanation were included in the file.
- 3.Ask the scan ordering office whether it submitted the records supporting the request.
- 4.Keep the denial notice, appeal request, fax confirmations, reference numbers and every later decision together.
For a standard reconsideration involving a service or item, the plan ordinarily must act as quickly as the person's health condition requires and within 30 calendar days after receiving the request. The rule permits an extension in certain circumstances. Ask the plan or IRE which deadline applies if the appeal is expedited or extended.
If the IRE says no
The IRE’s decision letter explains the next level: a hearing before an administrative law judge, if the amount in dispute meets that year’s threshold. You have 60 days from the IRE decision to request it. Your State Health Insurance Assistance Program (SHIP) helps with appeals for free.
Who handles the independent review?
C2C Innovative Solutions became the Part C IRE for appeal requests received on or after May 1, 2026. MAXIMUS continues handling requests it received on or before April 30, 2026.
Questions families ask
Do I have to send the appeal to the IRE myself?
When a Medicare Advantage plan upholds all or part of its denial after reconsideration, the plan must send the case file and a written explanation to the CMS contracted independent entity.
Is the IRE part of my Medicare Advantage plan?
No. The IRE is an independent, outside entity that contracts with CMS.
What can I do while the review is pending?
Confirm that the file was transferred. Ask the plan what it sent. Ask the scan ordering office whether its supporting records were included. Keep copies of all notices and submission confirmations.
How quickly will the IRE decide?
The independent entity must review the case as quickly as the person's health condition requires and within its applicable contract deadline. Ask the IRE which deadline applies to the case.
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