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How to Appeal a Medicare Part D Coverage Decision



There are five levels of appeals available to you. You must follow the order listed below.


1. Appeal through your plan

The first level of appeal is called a "redetermination." The plan’s initial denial notice will explain how to file this appeal. You must request this appeal within 60 calendar days from the date on the coverage determination notice.

You, your doctor or other prescriber, or your representative may request a standard or expedited redetermination. Standard requests must be made in writing, unless your plan allows you to file a standard request by telephone. Your request will be expedited if your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting for a standard decision. Your plan’s address and phone number is in your plan materials and will also be in any unfavorable coverage determination decision you get.

Once your plan gets your request for an appeal, the plan has 7 calendar days (for a standard request for coverage) or 72 hours (for an expedited request for coverage) to notify you of its decision.

A written request to appeal must include the following:
  • Your name, address, and the Medicare claim number (your Medicare number) shown on your Medicare card

  • The name of the prescription drug you want your plan to cover

  • Reasons why you are appealing

  • Your signature or the signature of your representative
You should send any supporting documentation that you believe may help your case,including medical records, with your appeal request.



2. Review by an Independent Review Entity (called a "reconsideration")

If your Medicare drug plan makes an unfavorable redetermination decision, it will send you a written decision. If you disagree with the plan’s redetermination, you can request a review by an Independent Review Entity (IRE).

Tip: If your plan issues an unfavorable redetermination, it should also send you a "Request for Reconsideration" form that you can use to ask for a reconsideration. If you don’t get this form, call your plan and ask for it. You can also get this form by visiting www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp.

You or your representative must make a standard or expedited request in writing within 60 calendar days from the date of the plan’s redetermination decision. Your request must be sent to the IRE at the address or fax number listed in the plan’s redetermination decision. This decision letter will be mailed to you. Your reconsideration request will be expedited if the IRE determines, or your prescriber tells the IRE, that your life or health may be at risk by waiting for a standard decision.

Once the request for review has been filed, the IRE has 7 days (for a standard request for coverage or for a request to pay you back) or 72 hours (for expedited requests for coverage) to notify you of its decision.

The Part D QIC received 20,733 reconsideration requests during calendar year 2009. It is a 25% increase in the number of appeals received as compared to 2008. The majority of appeals are received January through April although requests are received in every month including December.

In 2009, the Part D QIC reversed plan decisions in 65% of cases, as follows:
Drug utilization management tool dispute: 71%
Out-of-network pharmacy coverage: 67%
Off-formulary exception request: 60%
Tiering exception request: 41%
Cost-sharing dispute: 21%

Most standard cases were processed in 6 days and most expedited cases were processed in 1 or 2 days.

Click below for:
Medicare Part D Reconsideration Appeals Data 2009   2008   2007   2006



3. Hearing with an Administrative Law Judge

You will receive a written decision from the IRE. If you disagree with the IRE’s decision, you or your representative can request an Administrative Law Judge (ALJ) hearing. You must make the request in writing within 60 calendar days from the date on the IRE’s decision letter. You must send your request to the location listed in the IRE’s decision letter. To get an ALJ hearing, the dollar value of your denied coverage must be at least a certain amount. For 2011, the dollar value of your denied coverage must be at least $130.(you may be able to combine claims to meet this dollar amount). The IRE’s decision will include the amount.

The ALJ hearing will be conducted by telephone or by video-teleconference. You may also request an in-person hearing. At the ALJ hearing, you will have the chance to explain why your Medicare drug plan should cover your drug or pay you back. You may also ask your doctor or other prescriber to join the hearing and explain why he or she believes the drug should be covered.



4. Review by the Medicare Appeals Council

You will receive a written decision from the ALJ. If you disagree with the ALJ’s decision, you or your representative can request a review by the Medicare Appeals Council (MAC). You must make the request to the MAC in writing within 60 calendar days from the date on the ALJ’s decision letter. Send your request to the location listed in the ALJ’s decision letter.



5. Review by a Federal court

You will receive a written decision from the MAC. If you disagree with the MAC’s decision, you or your representative can request a review by a Federal court. You must make the request in writing within 60 calendar days from the date of the MAC’s decision notice. You should check with the clerk’s office of the Federal court for instructions about how to file the appeal. The court location will be listed in the MAC’s decision notice. To get a review by a Federal court, the dollar value of your denied coverage must be at least a certain amount. For 2011, the dollar value of your denied coverage must be at least $1,300. (You may be able to combine claims to meet this dollar amount). The MAC’s decision will include the amount.

CMS Medicare Part D Appeals Process Flowchart

. . . . . . . . .
  Medicare Prescription Drug (Part D)  
  
Coverage Determination*/Appeals Process
  
  .  
 
Standard Process
72 hour time limit**
 
Expedited Process
24 hour time limit**
Coverage Determination
. . .
60 days to file a request for redetermination
 
PDP/MA-PD
Standard Redetermination
7 day time limit
 
PDP/MA-PD
Expedited Redetermination
72 hour time limit
First Appeal
Level
. . .
60 days to file a request for reconsideration
 
Part D Independent Review Entity (IRE) or QIC
Standard Redetermination
7 day time limit
 
Part D Independent Review Entity (IRE) or QIC
Expedited Redetermination
72 hour time limit
Second Appeal Level
see PDP & MA-PD QIC/IRE address/fax below
. . .
60 days to file
 
Office of Medicare Hearings and Appeals
Administrative Law Judge (ALJ) Hearing
Standard Decision
Amount in Controversy (AIC) >$130***
90 day time limit
 
Office of Medicare Hearings and Appeals
Administrative Law Judge (ALJ) Hearing
Expedited Decision
Amount in Controversy (AIC) >$130***
10 day time limit
Third Appeal Level
. . .
60 days to file
 
Medicare Appeals Council
Standard Decision
90 day time limit
 
Medicare Appeals Council
Expedited Decision
10 day time limit
Fourth Appeal Level
. . .
60 days to file
  
Federal District Court
Amount in Controversy (AIC) > $1,300***
 Fifth Appeal Level
 

Notes:
 
Mailing and Fax for Second Level Appeals QIC/IRE (Effective Nov. 8, 2010):
 
For All Drug Benefit (PDP & MA-PD)
Reconsiderations
:

MAXIMUS Federal Services
Medicare Part D QIC
860 Cross Keys Office Park
Fairport, NY 14450

Fax numbers: (585) 425-5390
Toll free fax: (866) 825-9507
Customer Service: 585-425-5300
Toll Free Customer Service:
877-456-5302

For Late Enrollment Penalty (LEP) Reconsiderations:
MAXIMUS Federal Services
Medicare Part D QIC
P.O. Box 991
Victor, NY 14564-0991

Fax numbers: (585) 869-3320
Toll free fax: (866) 589-5241
Customer Service: 585-425-5300
Toll Free Customer Service: 877-456-5302
 

AIC: Amount in Controversy -- AIC must be greater than $130 for third level appeals and AIC must be greater than $1,300 for Judicial Review
ALJ: Administrative Law Judge -- third level appeals
IRE: Independent Review Entity also known as a Qualified Independent Contractor (QIC) -- second level appeals
MA-PD: Medicare Advantage plan with Prescription Drug (Part D) benefits
PDP: Prescription Drug plan (drug only benefits -- no health benefits)
QIC: Qualified Independent Contractor also known as an Independent Review Entity (IRE) -- second level appeals

*A request for a coverage determination includes a request for a tiering exception or a formulary exception. A request for a coverage determination may be filed by the enrollee, the enrollee’s appointed representative or the enrollee’s physician or other prescriber.

**The adjudication timeframes generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication timeframe begins when the plan sponsor receives the physician’s supporting statement.

***The AIC requirement for an ALJ hearing and Federal District Court is adjusted annually in accordance with the medical care component of the consumer price index. The chart reflects the amounts for calendar year (CY) 2011.



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