Medicare Part D Appeals Process
Medicare Part D is a prescription drug benefit program that is offered exclusively through commercial health plans that contract with Medicare. Medicare advocates are available to assist beneficiaries with the appeals process. However, the appeal should be carefully managed to ensure that it is properly prepared and submitted.
There are currently five levels of Medicare Part D appeals1:
- Level 1: Redetermination
- Level 2: Reconsideration
- Level 3: Administrative Law Judge (ALJ) Hearing
- Level 4: Medicare Appeals Council (MAC)
- Level 5: Federal District Court Hearing
Each level of appeal must be completed before the next level of appeal can be initiated. In addition, there are time and dollar thresholds that must be met.
Use the following illustration below as a guide in completing a Medicare Part D appeal.1 Each level of appeal should be carefully managed, as there are different timing requirements for filing each appeal.
- AIC = Amount in controversy
- ALJ = Administrative law judge
- MA-PD = MediShip-to-Patient Option plan that offers Part D benefits
- PDP = Prescription drug plan
- QIC = Qualified independent contractor
- *The adjudication time frames generally begin when the plan sponsor receives the request. However, if the request involves an exception request, the adjudication time frame begins when the plan sponsor receives the physician's supporting statement.
- † The adjudication time frames generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication time frame begins when the plan sponsor receives the physician's supporting statement.
- ‡The dollar amount in controversy increases annually by the amount of the consumer price index for all urban consumers (U.S. City average). Revised dollar thresholds are announced by the Centers for Medicare and Medicaid Services.