Reconsiderations by the Independent Review Entity
If a Part D plan sponsor issues an unfavorable redetermination decision, the enrollee, the enrollee's representative, or the enrollee's prescriber 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.
For more information about appointing a representative, see section 20 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, using the link in the "Downloads" section below.
How to Request a Reconsideration
An enrollee, an enrollee's representative, or an enrollee's prescriber may request a standard or expedited reconsideration.
- The request must be filed with the IRE within 60 calendar days from the date of the plan sponsor's redetermination decision notice.
- All requests must be made in writing, which includes by fax.
- An enrollee, an enrollee's representative, or an enrollee's prescriber may use the model "Request for Reconsideration of Medicare Prescription Drug Denial" form to request a reconsideration with the IRE (using the left navigation menu, go to the "Forms" webpage).
If a Medicare prescription drug (Part D) plan enrollee wants to appeal a Part D plan's unfavorable redetermination, the appeal request must be sent to the IRE, Maximus, at the following address:
Maximus Federal Services
3750 Monroe Avenue
Pittsford, NY 14534-1302
Maximus' website has many features that allow enrollees, enrollee representatives, plan sponsors, and physicians or other prescribers to obtain information regarding the Medicare Part D reconsideration process. To access Maximus' website, use the link titled "Maximus Part D Appeals website" in the "Related Links" section below. Also provided in the "Related Links" section below is a link to the Medicare Reconsideration Part D QIC Manual (click on the "Part D QIC Manual" link).
How the IRE Processes Reconsideration Requests
Once the benefit request is received by the IRE, the IRE must make its decision and provide written notice 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 from receipt of the request. For payments, the IRE must make its decision and provide written notice of their decision (and instruct plans to make payment, when appropriate) within 14 calendar day after receiving a request. For expedited reconsiderations, initial notice may be provided verbally, so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification.
If the decision is unfavorable, the decision will contain the information needed to file a request for a hearing with an Administrative Law Judge within the Office of Medicare Hearings and Appeals (OMHA). Parties to the hearing may waive their right to the oral hearing and request that a decision be made based on the record. Use the left navigation menu on this page to link to other pages that contain detailed information about hearings with an ALJ and obtaining an on the record review by OMHA, or any other level of appeal.
Fact Sheet: Part D Benefit 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 link "Fact Sheets Part D Reconsideration Appeals Data" link in the "Downloads" section below.