Medicare Part D Appeals Process Chart
| Medicare Prescription Drug (Part D) | ||||||||
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| Coverage Determination | ||||||
| 60 days to file a request for redetermination | ||||||||
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| First Appeal Level | ||||||
| 60 days to file a request for reconsideration | ||||||||
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| Second Appeal Level see PDP & MA-PD QIC/IRE address/fax below | ||||||
| 60 days to file | ||||||||
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| Third Appeal Level | ||||||
| 60 days to file | ||||||||
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| Fourth Appeal Level | ||||||
| 60 days to file | ||||||||
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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. | ||||||||