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Medicare Part D Appeals Process Chart

. . . . . . . . .
  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:
 
The IRE/QIC handling both Drug Benefit and Late Enrollment Penalty Reconsiderations is determined based on your initial and follow-up appeals dates:

As noted on the C2C Innovative Solutions, Inc. website (c2cinc.com),
"Effective February 1, 2021, C2C Innovative Solutions, Inc. (C2C), is the Part D QIC; therefore, [C2C is] adjudicating new reconsideration requests received on and after February 1, 2021. There will be a short period in which both C2C and Maximus, the outgoing QIC, are processing reconsiderations. Maximus will continue posting effectuation, case file submission information, and appeals received/decided for reconsideration requests received on or before January 31, 2021 and reopening requests for drug benefit appeals received on or before March 31, 2021 and reopening requests for LEP appeals received on or before April 16, 2021. PDP and MA-PDP Plans should return case files to Maximus, when Maximus has requested the case file."
Mailing and Fax for Second Level Appeals QIC/IRE:
 
For All Drug Benefit (PDP & MA-PD)
Reconsiderations
:


C2C Innovative Solutions, Inc.:
via U.S. Postal Service (USPS):
C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations
P.O. Box 44166
Jacksonville, FL 32231-4166

via UPS / FedEx ONLY:
C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202

Telephone for Enrollees Only: (833) 919-0198 (Toll Free)
Fax for Enrollees Only - Expedited Appeals: (833) 710-0579 (Toll Free)
Fax for Enrollees Only - Standard Appeals:(833) 710-0580 (Toll Free)

For more information:
C2C Appeal Instructions and links

MAXIMUS Federal Services:

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:

C2C Innovative Solutions, Inc.:
via U.S. Postal Service (USPS):
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231-4165

via UPS / FedEx ONLY:
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202

Telephone for Enrollees Only: (833) 919-0198 (Toll Free)
Fax for Enrollees Only:(833) 946-1912 (Toll Free)


For more information:
C2C Appeal Instructions and links

MAXIMUS Federal Services:

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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