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If a Part D plan sponsor issues an adverse redetermination decision, the enrollee may appeal the decision to the Independent Review Entity (IRE), also commonly called the Part D Qualified Independent Contractor (QIC), by requesting a reconsideration. Currently, MAXIMUS Federal Services is the Part D IRE. An enrollee or an enrollee's appointed representative may request a standard or expedited reconsideration. An enrollee's prescribing physician may not request a reconsideration on an enrollee's behalf unless the enrollee's physician is also the enrollee's appointed representative. For more information about appointing a representative, see section 10.4 in Chapter 18 of the Prescription Drug Benefit Manual. You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" section below. How to Request a Reconsideration The request must be filed with the IRE within 60 calendar days from the date of the notice of the plan sponsor's redetermination decision. All requests must be made in writing, which includes by fax. A beneficiary or a beneficiary's appointed representative may use the model "Request for Reconsideration of Medicare Prescription Drug Denial" form to request a reconsideration with the IRE. The request form is contained in Appendix 13 to Chapter 18 of the Prescription Drug Benefit Manual. You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" section below. If a member is enrolled in a Medicare Advantage plan that offers prescription drug benefits (MA-PD) and is appealing an unfavorable redetermination decision to the Part D IRE, he or she must send the appeal request to MAXIMUS's Victor, NY office. If a member is enrolled in a standalone Prescription Drug Plan (PDP) and is appealing an unfavorable redetermination decision to the Part D IRE, he or she must send the appeal request to MAXIMUS's King of Prussia, PA office. For more information about how to file appeals with the IRE, you may click on the "Part D QIC Manual" link in the "Related Links Outside CMS" section below. How the IRE Processes Reconsideration Requests Once the request is received by the IRE, it must make its decision and notify the enrollee of its decision as quickly as the enrollee's health requires, but no later than 72 hours for expedited requests or 7 calendar days for standard requests after receiving the request. If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a hearing with an Administrative Law Judge (ALJ). Use the navigation tool on the left side of this page to link to subpages that contain detailed information about hearings with an ALJ or any other level of appeal. Fact Sheet: Part D Reconsideration Appeals Data These reports summarize and highlight some of the key data on reconsiderations since the inception of the Medicare prescription drug benefit program on January 1, 2006. To view the Fact Sheets, click on the links in the "Downloads" section below.
Page Last Modified: 05/13/2008 10:51:10 AM
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