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What are the different levels of the Medicare plan appeals process?

Category: General Medicare
Updated: Jul, 19 2023


An appeal is the process members can use when the plan makes a decision to deny coverage for a drug.  The member, the member's appointed representative, or, in some cases, the member's doctor can submit an appeal request. There are five levels in the appeals process:

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.

*An expedited decision is requested based on the urgency of a member's health condition.


Five (5) things to know when filing an appeal
  1. If you decide to file an appeal, ask your doctor, health care provider, or supplier for any information that may help your case.

  2. If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. If the plan or doctor agrees, the plan must make a decision within 72 hours.

  3. The plan must tell you, in writing, how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan doesn't decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.

  4. If you believe you're being discharged from a hospital too soon, you have a right to immediate review by your Beneficiary And Family Centered Care Quality Improvement Organization (Bfcc-Qio). You'll be able to stay in the hospital at no charge while they review your case. The hospital can't force you to leave before the BFCC-QIO reaches a decision.

  5. You'll have the right to a fast-track appeals process when you disagree with a decision that you no longer need services you're getting from a skilled nursing facility, home health agency, or a comprehensive outpatient rehabilitation facility.



Question:  Can someone file an appeal for me?

Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.

Or, you can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, financial advisor, doctor, or someone else who will act on your behalf.


Question: How do I appoint a representative?
  • Fill out an “Appointment of Representative” form [PDF, 47.7KB].

  • Or, submit a written request with your appeal that includes:

    • Your name, address, phone number, and Medicare Number
    • A statement appointing someone as your representative
    • The name, address, and phone number of your representative
    • The professional status of your representative (like a doctor) or their relationship to you
    • A statement authorizing the release of your personal and identifiable health information to your representative
    • A statement explaining why you’re being represented and to what extent

  • Send the representative form or written request with your appeal to the Medicare Administrative Contractor (MAC) (the company that handles claims for Medicare), or your Medicare health plan.

If you have questions about appointing a representative, call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.

(Source: U.S. Department of Health & Human Services)





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