Part D RAC Appeals Process

Part D RAC Appeals Process

If a plan sponsor receives a Notice of Improper Payment (NIP), the Medicare Part D RAC has determined an overpayment to the plan sponsor. The plan sponsor can appeal this finding. There are three levels of appeal: Level I: Request for Reconsideration; Level II: Request for CMS Hearing Official Review; and Level III: Request for CMS Administrator Review. This page will assist you in understanding this process and how to file an appeal.

Information on this page includes:

See below for a graphical display of the key components of the appeals process. Click to enlarge: Infographic Appeals Process (PDF)

infographic describing appeals process (all text contained on this page)

When must appeals be filed?

The appeals deadlines are as follows:

01

Level I: Request for Reconsideration

A Request for Reconsideration, must be filed no later than 60 calendar days from the date of the issuance of a Notice of Improper Payment (NIP).  The NIP indicates the audit issue being reviewed, the applicable laws, the amount of the overpayment, how it was calculated and the plan sponsor's appeal rights. If an appeal with supporting documentation is not received within 60 days, payment collection will be initiated. All relevant issues must be raised at the time of the Level I appeal. Issues that are not raised in the Level I appeal cannot be raised at a later time and will be dismissed.

02

Level II: Request for CMS Hearing Official Review

Requests for a CMS Hearing Official Review, must be filed no later than 30 calendar days from the issuance date of the Reconsideration decision. The request must include a detailed narrative of why each Reconsideration decision is incorrect.

03

Level III: Request for CMS Administrator Review

Request for CMS Administrator Review, must be filed no later than 30 calendar days from the issuance date of the Hearing Official's decision. The request must include a detailed narrative of why the Hearing Official's decision is incorrect. The Administrators decision is final.

Note: Appeals that are submitted after the established deadline will be dismissed without the ability to re-file. If the deadline falls on a weekend or a Federal Holiday, the filing period will be extended to the next business day.

Electronic submissions will be considered timely if they are received in the designated appeals mailbox by 11:59 EST on the deadline date. Physical submissions that are mailed must be postmarked by the date of the deadline.

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Who can appeal?

All Part D plan sponsors receiving a Notification of Improper Payment can appeal.

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Notification of Improper Payment (NIP)

The Notification of Improper Payment indicates the audit issue being reviewed, the applicable laws, the amount of the overpayment, how it was calculated and the plan sponsor’s appeal rights. The Improper Payment Exception Report, an encrypted file sent with the NIP, will include the PDE records associated with this improper payment.

A Part D plan sponsor who receives a NIP should research the findings and determine whether to pursue a Request for Reconsideration (Level I Appeal). The NIP will identify a phone number and e-mail to reach the RAC if there are specific questions about the NIP or the RAC process. Additionally, the letter will provide Part D plan sponsors with information on the amount of overpayment identified, the process of recoupment, and appeal information.

CMS will make an interim adjustment to the plan sponsor’s monthly payment in the amount owed, which the Plan Payment Report will reflect after the 45-day accept/reject period for CMS Administrator Review requests. It is the responsibility of the plan sponsor to delete the PDE records identified in the Improper Payment Exception Report to correct any errors identified by the RAC within 90 days of the NIP or final appeal decision. If the affected PDE records are deleted within the required timeframe, the interim adjustment will be credited back to the plan sponsor.

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What is appealable?

The Part D plan sponsor may appeal the determination made by the Part D RAC that an overpayment was made to the Part D plan sponsor as a result of improper payments made by the Part D plan sponsor for a given issue (e.g. excluded providers, unauthorized prescriber, etc.). The Part D plan sponsor may also appeal the amount of the overpayment.

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What is NOT appealable?

This appeals process prohibits the Part D plan sponsor from appealing the methodology and standards used to identify and calculate the overpayment(s).

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What are impact calculations and how are they conducted?

The impact of Part D RAC-identified overpayments is determined by calculating the effect of the overpayment on reinsurance and low-income cost sharing amounts. A reconciliation based on corrected payments is performed and then compared to the initial reconciliation to determine the total overpayment. The amount is reflected in the NIP as the interim offset amount.

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How will CMS recoup the identified overpayment?

An interim adjustment in the amount owed will be made to a contract’s monthly payment. This will be reflected in the Part D plan sponsor’s Membership Detail Report approximately 2 months from the date of the NIP. Prior to CMS reopening reconciliation, this offset will be credited at the contract level. PDE records identified by the RAC that were originally paid in error must be submitted to CMS by the Part D plan sponsor immediately. The interim payment adjustment will be reversed during the reopening of reconciliation. Overpayment adjustment dates will be communicated to the Part D plan sponsor in the Plan Payment Letter that they receive from the Medicare Plan Payment Group.

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General requirements for filing an appeal

icon of pencil and paper

Include all relevant issues in the initial appeal: Part D plan sponsors must raise all relevant issues at the time of the Request for Reconsideration. Issues that are not raised in the Request for Reconsideration cannot be raised at a later time and will be dismissed. Part D plan sponsors may amend the Request for Reconsideration if they need to include additional information that may be relevant to their argument. Amendments must be submitted before the appeal timeframe expires. The Level I 60-day appeal deadline does not change upon the receipt of appeal or upon the receipt of an appeal amendment.

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Where do I send the request for an appeal?

Use this format

Email Appeal Requests

  1. For a Level I Appeal, include the contract number and the phrase "RAC Reconsideration Request" or must be in the subject line of the email (e.g "H1234 RAC Reconsideration Request"). The appeal submission must include all relevant information and be well organized.
  2. Documentation shall be submitted to CMS by Contract # using the template provided by CMS (all templates can be found below and on the Resource Page). If the Part D plan sponsor is requesting an appeal for multiple contracts, the Part D plan sponsor must submit a separate email request for each contract; all supporting documentation should be carefully categorized, clearly legible, easily understood and cross referenced where necessary. All relevant information to the appeal of this notification should be included in this initial submission to be considered for review.
  3. If a Part D plan sponsor is not satisfied with Reconsideration Decision, the sponsor has 30 calendar days from the date of receipt of the decision to make a Request for Hearing Official Review. The Request for Hearing Official Review must be e-mailed to CMS at CMSHearingOfficial_Review@cms.hhs.gov. The contract number and the phrase "RAC Request for Hearing Official Review" must be in the e-mail’s subject line (example, "H1234 RAC Request for Hearing Official Review").

Physical Appeal Requests: All physical appeal requests must be submitted on CD to the following address:

Centers for Medicare & Medicaid Services (CMS)
Division of Plan Oversight and Accountability
ATTN: "RAC Reconsiderations"
Mailstop: AR-21-55
7500 Security Boulevard
Baltimore, Maryland 21244

Withdrawing an appeal:

Part D plan sponsor may withdraw an appeal at Levels I or II at any time prior to a decision being issued.

All Level I withdrawal requests should be submitted via email to
PartDRACReconsiderations@cms.hhs.gov.

All Level II withdrawal requests should be submitted to
CMSHearingOfficial_Review@cms.hhs.gov

Page Last Modified:
09/06/2023 04:57 PM
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