Review by the Medicare Appeals Council

If an Administrative Law Judge (ALJ) issues an adverse decision, the enrollee or the enrollee's representative may appeal the decision by requesting a review by the Medicare Appeals Council (Appeals Council).

An enrollee's prescriber may not request a review by the Appeals Council on an enrollee's behalf unless the enrollee's prescriber 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 Review by the Appeals Council

The request must be filed with the Appeals Council within 60 calendar days from the date the ALJ's decision notice.

Requests for standard reviews must be made in writing, which includes by fax.  Requests for expedited reviews may be made orally or in writing.

The request may be made on Appeal Form DAB-101, which can be obtained by clicking on the link in "Related Links" section below.

For more information about how to request a review with the Appeals Council, you may click on the related link in the "Related Links" section below.

Also, section 100 in Chapter 18 of the Prescription Drug Benefit Manual contains more information about the Appeals Council process.  You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" section below.

If the Appeals Council's decision is unfavorable, the decision will contain the information needed to file a request for review by a Federal District Court.

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about reviews by a Federal District Court or any other level of appeal.