What is an Appeal?:QuickMedicareSupplement.com

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What is an Appeal?

What is an Appeal?

An appeal is the procedure members can use when the plan makes a conclusion to deny coverage for a drug. The member, the member's chosen representative, or, in a few cases, the member's doctor can put forward an appeal request. There are five levels in the appeals process:

1. Level One - Redetermination by the Plan

Standard Appeal:

-If the planís coverage determination is unfavorable, a member or a member's representative may request a standard redetermination. The plan has up to 7 days to issue its conclusion.

Expedited Appeal:

-Same as standard, except for the memberís doctor may also request an expedited redetermination. The plan has up to 72 hours to issue its choice.

2. Level Two - Reconsideration by the Part D Qualified Independent Contractor (QIC)

Standard Appeal:

-If the planís redetermination is unfavorable, a member or a member's appointed representative can request reconsideration by the Part D QIC, which is a CMS contractor that reviews plan decisions. The QIC has up to 7 days to issue its decision.

Expedited Appeal:

-Same as standard, except the time is up to 72 hours for the Part D QIC to issue its decision.

3. Level Three - Administrative Law Judge (ALJ)

Standard Appeal:

-If the Part D QICís reconsideration is unfavorable, a member or a member's appointed representative can request a hearing with an ALJ if the amount remaining in controversy requirement is satisfied.

Expedited Appeal:

-Not appropriate.

4. Level Four - Medicare Appeals Council (MAC)

Standard Appeal:

-If the ALJís finding is unfavorable, a member or a member's chosen representative can appeal to the MAC, an entity within the Department of Health and Human Services that reviews ALJ decisions

Expedited Appeal:

-Not appropriate

5. Level Five - Federal District Court

Standard Appeal:

-If the MACís decision is unfavorable, a member or a member's selected representative can appeal to a Federal district court, if the amount remaining in controversy condition is satisfied.

Expedited Appeal:

-Not appropriate

An expedited decision is requested based on the urgency of a member's health state.

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