Medicare Advantage's expedited reconsideration has a 72-hour deadline
A plan must expedite when a physician says the standard timeframe could seriously jeopardize the patient's life, health, or ability to regain maximum function.
Head of Growth and Operations, JotPsych
Your patient's Medicare Advantage plan denied prior authorization for an item or service. The 30 days of a standard reconsideration could seriously jeopardize your patient's health. Call the plan. Ask for an expedited reconsideration, the fast first level of appeal.
What to say on the call
Say that the standard timeframe could seriously jeopardize your patient's life, health, or ability to regain maximum function. Use those exact words from section 422.584.
I'm Dr. (name), calling on behalf of my patient, (patient name), member ID (number).
I request an expedited reconsideration of your prior authorization denial dated (date) for (service).
Applying the standard timeframe could seriously jeopardize my patient's (life, health, or ability to regain maximum function).
Your notice gives this reason: (quote it). My notes answer it: (each note and its date).
Please record this request in writing and tell me the time you received it.
The highlighted line uses the words of 42 CFR 422.584(c)(2)(ii), which requires the plan to expedite a request when a physician says those words. Without that line, the plan can move your request to the standard timeframe.
You can ask by phone or in writing. You don't need to be affiliated with the plan. The plan must write down your phone request and keep it in the case file, and the plan can't take or threaten punitive action against you for asking. Note the time of your call.
42 CFR 422.590(e) in the Code of Federal Regulations sets the 72 hours for an item, a service, or a Part B drug. Make the request the day you read the denial, so the 72 hours start that day.
What the plan must do next
By the 72-hour deadline, the plan must decide and notify your patient, per section 422.590. For an item or service, the plan can add up to 14 calendar days in only three cases and must give your patient the reasons in writing.
- Your patient asks for the extension.
- The plan needs evidence from a noncontract provider that may change the denial, and the extension serves your patient.
- Extraordinary, exigent, or other non-routine circumstances justify the extension, and it serves your patient.
Part B drugs get no extension. If the plan upholds any part of the denial, the case goes to Medicare's independent reviewer within 24 hours. You don't file again. The plan's missed deadline counts as an upheld denial, and the case goes to the independent reviewer too. Part D drugs follow other rules, in section 423.590.
When to file
Standard requests have the same 60-day filing deadline as expedited ones, per section 422.582. The rule presumes the denial notice arrived 5 calendar days after its date, and your request counts as filed on the day the plan receives it.
Medicare Advantage insurers partly or fully overturned more than 8 in 10 appealed denials each year from 2019 through 2024, per KFF’s review.
KFF's analysis of 2024 Medicare Advantage prior authorization data for all items and services, published January 28, 2026. Appeal your patient's denial when your notes answer the denial's reason.
What to send after the call
Send written support, as paragraph (b)(2) of section 422.584 allows: a letter of medical necessity and the notes your call cites. KFF notes that some overturns may mean the first request lacked documentation.
Select Documents on your patient's latest note, ask for a letter of medical necessity, and JotPsych drafts it.
Book 15 minutes- KFF, “Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024”, January 28, 2026.
- 42 CFR 422.582, request for a standard reconsideration, paragraph (b).
- 42 CFR 422.584, expediting certain reconsiderations, paragraphs (a) to (d) and (f); read October 3, 2026.
- 42 CFR 422.590, timeframes and responsibility for reconsiderations, paragraphs (e) to (g).
- 42 CFR 423.590, timeframes and responsibility for making redeterminations.