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.
An enrollee, an enrollee's representative or an enrollee's prescriber may request a standard or expedited reconsideration.
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.
- 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. 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 Medicare prescription drug plan (Part D) 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:
3750 Monroe Avenue
Pittsford, NY 14534-1302
Maximus' website has many features that allow enrollees and 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 request is received by the IRE, it must make its decision and provide 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 expedited reconsiderations, initial notice may be provided orally, so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the oral 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 (ALJ) or a review of the administrative record by an attorney adjudicator within the Office of Medicare Hearings and Appeals (OMHA).
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 Benefit and Late Enrollment Penalty (LEP) 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. Effective 2015, LEP data is also available. To view the Fact Sheets, click on the link "Fact Sheets Part D Reconsideration Appeals Data" link in the "Downloads" section below.
- Page last Modified: 06/28/2018 10:36 AM
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