The drug plan customer service data comes from several sources. The information about appeals comes from an independent reviewer (also known as the Independent Review Entity or (IRE). This organization evaluates the drug plan’s appeals decisions.
Additional data source information for each sub-category is outlined below.
Call Center — Foreign Language Interpreter and TTY Availability
Availability of TTY services and foreign language interpretation when prospective members call the drug plan.
Percent of the time that the TTY services and foreign language interpretation were available when needed by prospective members who called the drug plan’s prospective enrollee customer service phone number.
The information about the availability of TTY services and foreign language interpretation comes from systematic studies that Medicare does to check on how well the plan is handling calls from prospective members.
Drug Plan Fails to Make Timely Decisions about Appeals
Percent of plan members who failed to get a timely response when they made an appeal request to the drug plan about a decision to refuse payment or coverage. If you would like more information about Medicare appeals, click on http://www.medicare.gov/claims-and-appeals/index.html
Appeals Auto—Forward Data Source:
The information about whether the drug plan is making timely appeal decisions comes from an independent reviewer (also known as the Independent Review Entity or IRE). If the drug plan does not meet Medicare’s deadlines for providing the appeal decision, the appeal case is sent to the independent reviewer. This measure shows the rate (per 10,000 members) of cases sent to the independent reviewer because the plan did not make a timely decision.
Fairness of Drug Plan’s Appeal Decisions
Fairness of Drug Plan’s Appeal Decisions, Based on an Independent Reviewer
This measure/rating shows how often an Independent Reviewer thought the drug plan’s decision to deny an appeal was fair. This includes appeals made by plan members and out-of-network providers. (This rating is not based on how often the plan denies appeals, but rather how fair the plan is when they do deny an appeal.)
Appeals Upheld Data Source:
The information about whether the drug plan is making fair appeal decisions comes from an independent reviewer (also known as the Independent Review Entity or IRE). This organization evaluates Part D appeals after the drug plan’s review. This measure shows the percent of cases in which the independent reviewer agreed with the drug plans’ decision.