Glossary
Appeal
In one sentence
A review, by the plan that said no, of its own adverse benefit determination. It is not the state hearing and it is not a complaint, and in managed care it usually has to happen before the state will look at the case.
What appeal actually means
The word does a lot of work in benefits and it is worth being precise about. In Medicaid managed care an appeal is the plan reviewing itself. It is a defined step with its own deadline, and it is generally the step that comes first.
What people often mean by "appeal" is the state fair hearing, which is a different proceeding in front of the state rather than the plan. Both may be available to you, but they are sequential rather than interchangeable in most managed care programs, and asking the wrong body first can cost time you do not have.
Medicare Part D uses the word more broadly, to name the whole ladder rather than one rung of it. On our Part D page that ladder starts with a redetermination by the plan.
The text it comes from
This is the wording the definition rests on. Where it decides anything for you, read the section rather than our summary of it.
The Medicaid managed care definition is one sentence long and puts the review with the plan: "Appeal means a review by an MCO, PIHP, or PAHP of an adverse benefit determination."
42 CFR §438.400(b), Electronic Code of Federal Regulations, effective August 2026 · source
Medicare Part D uses the same word for the entire sequence rather than one step: "Appeal means any of the procedures that deal with the review of adverse coverage determinations made by the Part D plan sponsor." It then names the rungs — "redeterminations by the Part D plan sponsor, reconsiderations by the independent review entity, ALJ hearings, reviews by the Medicare Appeals Council (Council), and judicial reviews."
42 CFR §423.560, Electronic Code of Federal Regulations, effective August 2026 · source
Where this comes from
- 42 CFR §438.400(b), Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-42/part-438/section-438.400
- 42 CFR §423.560, Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-42/part-423/section-423.560
Where this comes up
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page says what a published rule means by a word. Which rulebook governs you depends on your plan, and your own notice and plan documents govern your case.