.
.
.
. . .
. . .
Q1 Medicare.com Click to Enter Your Drugs and Compare Medicare Part D Plans
Powered by Q1Group LLC Powered by Q1Group LLC.
Education and Decision Support Tools for the Medicare Community
.
. . .
. . .
. . .
.
. Home Contact Us Enroll . .
. . MAPD PDP 2014 FAQ Blog
.
. . .
. . . . . . .
.
.
: : Compare 2013 Medicare Rx and Health Plans by Drug Costs
: : See 2013 Medicare Drug Plans
: : 2013 Medicare Advantage Plans
: : Browse Any 2013 Plan Formulary
: : Compare a Drug's Coverage Across All 2013 Drug Plans
: : Newsletter Sign-up
. . . .
Special Features
Find a 2013 Part D Plan (Rx Only)
Find a 2013 Medicare Advantage Plan (Health and Health w/Rx Plans)
Browse Any 2013 Medicare Plan Formulary (or Drug List) Updated!
Find a 2013 Medicare Part D or Medicare Advantage Plan by Drug
Compare Part D and Medicare Advantage Plans by Drug Costs
2013 National Plan Overview by State
PDP and MAPD Overview by State
PDP Overview by CMS Region
Medicare Part D
Medicare Part D - Blog
Enrollment Tips
2013 Medicare Part D Plan Information
2014 Medicare Part D Outlook
Medicare.gov Tutorial
The Basics of Medicare Part D
The Donut Hole and Beyond
How Part D Plans Work
Which Drugs are Covered?
Which Drugs are Excluded?
Understanding Your Explanation of Benefits
Formulary Exceptions
(Coverage Determinations),
Appeals & Grievances
How to Request a Coverage Determination, File an Appeal, or File a Complaint
Prescribing Physician’s Role in Processes
Plan Sponsor Contacts for Exceptions & Appeals
Part D Appeals Process Chart
Appealing SSA's "Extra Help" Decision
Appealing the Late Enrollment Penalty
Income Related Monthly Adjustment Amount (IRMAA) Appeals
Choosing a Plan: The Basics
Your Medicare Part D Checklist
Tips from CMS
Important Dates
The Late Enrollment Penalty
Out-of-Pocket Cost Estimator
After Enrollment into Part D
Financial "Extra Help"
Part D Scams - Watch Out!
Doughnut Hole Calculator
Medicare Advantage Plans
2013 Medicare Advantage Plan Benefit Details
Medicare Advantage Plans State Overview
Find a Medicare Advantage Plan by Drug Costs
Medicare Overview
Medicare & You Handbook
Guide to Rx Coverage
Plan Archives
Support Center
Medicare.gov Tutorial


. .

Prescribing Physician’s Role in Coverage Determinations and Exceptions, Appeals & Grievances Processes
The enrollee, enrolee’s physician and/or enrollee’ appointed representative can file a coverage determination (including tiering exception or formulary exception). The adjudication timeframe begins when the plan sponsor receives the physician’s supporting statement.

CMS provides dedicated help for physicians through eMail at PRIT@cms.hhs.gov.

Short Decision Making Timeframes

CMS has directed every prescription drug plan to respond to requests without delay. Plans must communicate decisions on initial coverage determinations no later than 24 hours after receiving an expedited request, or 72 hours after receiving a standard request. If a prescribing physician requests a coverage determination on behalf of an enrollee, the physician also will receive notice of the decision from the plan. Coverage determinations include decisions on formulary and tiering exception requests. If the plan fails to meet the timeframe, the case goes to an independent review entity under contract with CMS for a decision on the case. The independent review entity is commonly referred to as the Part D qualified independent contractor (Part D QIC).

Please keep the 24 and 72 hour timeframe in mind when filing a request. Should the carrier/plan need to contact you for more information and your office is closed (i.e. weekends, holidays) the request will most likely be denied and you or your patient will need to file an appeal. Therefore, fully complete the request documentation and give a telephone number where that will be answered during the 24 or 72 hour time period.
:: Top

Requests Made by Prescribing Physicians

A coverage determination can be requested by a Part D plan enrollee, by an appointed representative or the prescribing physician on behalf of the enrollee. A prescribing physician can also request an expedited redetermination (first level of appeal) on behalf of the enrollee. Prescribing physicians cannot request a standard redetermination (first level of appeal) or a reconsideration (second level of appeal), unless they are the enrollee's appointed representative. Form CMS-1696 (Appointment Of Representative) or an equivalent writing can be used to appoint a representative.
:: Top

Prescribing Physician Supporting Statements

Prescribing physicians have an important role in the exceptions process. Whenever an enrollee requests a formulary or tiering exception, the prescribing physician must provide the Part D plan with an oral or written statement to support the exception request. Formulary exception requests include requests for exceptions to cost utilization management tools, such as step therapy or dose restrictions. The plan’s timeframe for making a decision on an exception request does not begin until the prescribing physician’s supporting statement is received by the plan. Anyone can go to our coverage determination site at: www.cms.hhs.gov/center/provider.asp to get contact numbers for the plans to facilitate the submission of the supporting statement.
:: Top

Enrollee’s Appeal Rights

If an enrollee doesn’t agree with the initial coverage determination made by the plan, the enrollee has the right to appeal the coverage determination. As noted above, the prescribing physician can ask for an expedited first level appeal (redetermination) on behalf of the enrollee. The following chart describes the steps and the time limits of the process. For expedited redeterminations, a Part D plan must give the enrollee (and prescribing physician involved, as appropriate) notice of its decision no later than 72 hours after receiving the request. Decisions on standard redeterminations must be communicated to the enrollee in writing no later than 7 days after receiving the request. If a plan issues an adverse redetermination, the enrollee will receive a notice that includes information on how to request a reconsideration by the Part D QIC.
:: Top

CMS Medicare Part D Appeals Process Flowchart

. . . . . . . . .
  Medicare Prescription Drug (Part D)  
  
Coverage Determination*/Appeals Process
  
  .  
 
Standard Process
72 hour time limit**
 
Expedited Process
24 hour time limit**
Coverage Determination
. . .
60 days to file a request for redetermination
 
PDP/MA-PD
Standard Redetermination
7 day time limit
 
PDP/MA-PD
Expedited Redetermination
72 hour time limit
First Appeal
Level
. . .
60 days to file a request for reconsideration
 
Part D Independent Review Entity (IRE) or QIC
Standard Redetermination
7 day time limit
 
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
. . .
60 days to file
 
Office of Medicare Hearings and Appeals
Administrative Law Judge (ALJ) Hearing
Standard Decision
Amount in Controversy (AIC) >$130***
90 day time limit
 
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
. . .
60 days to file
 
Medicare Appeals Council
Standard Decision
90 day time limit
 
Medicare Appeals Council
Expedited Decision
10 day time limit
Fourth Appeal Level
. . .
60 days to file
  
Federal District Court
Amount in Controversy (AIC) > $1,300***
 Fifth Appeal Level
 

Notes:
 
Mailing and Fax for Second Level Appeals QIC/IRE (Effective Nov. 8, 2010):
 
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
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
 

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.
:: Top
Click the +1 button if you have found this page useful:  

.
.
Medicare Supplements
fill the gaps in your
Original Medicare
1. Select Your State:
.


.
.

.
Medicare PartD MAPD and PDP plan comparisons .
Quick Links
: : Find a 2013 Plan by Drug Costs
: : 2013 Part D Plan Facts & Figures
: : 2013 Part D PDP-Finder (Drug Only) Plan Finder
: : Compare 2012/2013 PDP Plans
: : 2013 MA-Finder: Medicare Advantage Plan Finder
: : Compare 2012/2013 Medicare Advantage Plans
: : Guided Help Finding a 2013 Prescription Drug Plan
: : 2013 Part D Drug Finder
: : Browse Any 2013 Part D Plan Formulary
: : 2013 Browse Drugs By Letter
: : RxSavings-Center
: : 2014 Plan Information Reminder Service
.

: : Click here to link to this page on your website
.

    Follow Q1Medicare on Twitter
.

   
. . .
. . .
.
.
What’s New Most Viewed Press . .
.
. . .
.
Sitemap About Us Privacy Policy Newsletter Sign-up Blog FAQ Contact Us Terms Of Use Newsroom
. Enroll in Medicare Part D © Q1Group LLC 2005 - 2013 . .
. . .
. . .
.
.
. .

.
.
.