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| How to Appeal |
| Medicare Prescription Drug Coverage - How to File a Grievance or Appeal |
1. Appeal through your plan-The first level of appeal is called a “redetermination.” The plan’s initial denial notice will explain how to file this appeal. You must request this appeal within 60calendar days from the date of the coverage determination notice. You or your appointed representative must file a written standard request. Some plans will allow you to file a request by telephone. You, your appointed representative, or your doctor can call your plan or write to them for an expedited redetermination. Your request will be expedited if your plan determines, or your doctor tells your plan, that your life or health may be seriously jeopardized by waiting for a standard decision. Your plan’s address is in your plan materials and will also be in any unfavorable coverage determination decision you receive. Once your plan receives your request for an appeal, the plan has 7 calendar days (for a standard request for coverage or for a request to pay you back) or 72 hours (for an expedited request for coverage) to notify you of its decision. A written request to appeal must include the following:
2. Review by an Independent Review Entity (called a “reconsideration”) If you disagree with the plan’s redetermination, you can request a review by an Independent Review Entity (IRE). You or your appointed representative must make a standard or expedited request in writing within 60 calendar days from the date of the plan’s redetermination decision. Your request must be sent to the IRE at the address or fax number listed in the plan’s redetermination decision. This decision letter will be mailed to you. Your reconsideration request will be expedited if the IRE determines, or your doctor tells the IRE, that your life or health may be seriously jeopardized by waiting for a standard decision. 3. Hearing with an Administrative Law Judge-If you disagree with the IRE’s decision, you or your appointed representative can request an Administrative Law Judge (ALJ) hearing. You must make the request in writing within 60 calendar days from the date of the IRE’s decision letter. You must send your request to the location listed in the IRE’s decision letter that is mailed to you. To get an ALJ hearing, the projected value of your denied coverage must meet a minimum dollar amount (you may be able to combine claims to meet the minimum dollar amount). The IRE’s decision will include this amount. 4. Review by the Medicare Appeals Council If you disagree with the ALJ’s decision, you or your appointed representative can request a review by the Medicare Appeals Council (MAC). You must make the request to the MAC in writing within 60 calendar days from the date of the ALJ’s decision letter. You must send your request to the location listed in the ALJ’s decision letter that is mailed to you. 5. Review by a Federal court-If you disagree with the MAC’s decision, you or your appointed representative can request a review by a Federal court. You must make the request, in writing, within 60calendar days from the date of the MAC’s decision notice. You must send your request to the location specified in the MAC’s decision notice. To receive a review by a Federal court, the projected value of your denied coverage must meet a minimum dollar amount. The MAC’s decision will include the amount.
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