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| | | Medicare Prescription Drug (Part D) | | |
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Coverage Determination*/Appeals Process |
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Standard Process
72 hour time limit** |
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Expedited Process
24 hour time limit** |
| | Coverage Determination |
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| 60 days to file a request for redetermination |
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PDP/MA-PD
Standard Redetermination
7 day time limit |
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PDP/MA-PD
Expedited Redetermination
72 hour time limit |
| | First Appeal
Level |
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| 60 days to file a request for reconsideration |
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Part D Independent Review Entity (IRE) or QIC
Standard Redetermination
7 day time limit |
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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 |
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| 60 days to file |
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Office of Medicare Hearings and Appeals
Administrative Law Judge (ALJ) Hearing
Standard Decision
Amount in Controversy (AIC) >$130***
90 day time limit |
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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 |
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| 60 days to file |
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Medicare Appeals Council
Standard Decision
90 day time limit |
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Medicare Appeals Council
Expedited Decision
10 day time limit |
| | Fourth Appeal Level |
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| 60 days to file |
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Federal District Court
Amount in Controversy (AIC) > $1,300*** |
| | | Fifth Appeal Level |
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Notes:
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Mailing and Fax for Second Level Appeals QIC/IRE (Effective Nov. 8, 2010): |
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For All Drug Benefit (PDP & MA-PD)
Reconsiderations:
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
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For Late Enrollment Penalty (LEP) Reconsiderations:
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
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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. |
