Level | Standard Appeal | Expedited Appeal* | |
1 | Redetermination by the Plan | If the plan’s coverage determination is unfavorable, a member or a member's representative may request a standard redetermination. The plan has up to 7 days to issue its decision. | Same as standard except the member’s doctor may also request an expedited redetermination. The plan has up to 72 hours to issue its decision. |
2 | Reconsideration by the Part D Qualified Independent Contractor (QIC) also known as Independent Review Entity (IRE) |
If the plan’s redetermination is unfavorable, a member or a member's appointed representative can request a reconsideration by the Part D QIC, which is a CMS contractor that reviews plan decisions. The QIC has up to 7 days to issue its decision. | Same as standard except the timeframe is up to 72 hours for the Part D QIC to issue its decision. |
3 | Decision by the Office of Medicare Hearings and Appeals (OMHA) before an Administrative Law Judge (ALJ) | If the Part D QIC’s reconsideration is unfavorable, a member or a member's appointed representative can request a hearing with an ALJ if the amount remaining in controversy requirement is satisfied. | Not applicable. |
4 | Review by Medicare Appeals Council (MAC) | If the ALJ’s finding is unfavorable, a member or a member's appointed representative can appeal to the MAC, an entity within the Department of Health and Human Services that reviews ALJ decisions. | Not applicable. |
5 | Federal district court judicial review |
If the MAC’s decision is unfavorable, a member or a member's appointed representative can appeal to a Federal district court, if the amount remaining in controversy requirement is satisfied ($1,850 in 2023). | Not applicable. |