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If a Part D plan sponsor issues an adverse coverage determination, the enrollee may appeal the decision to the plan sponsor by requesting a redetermination. An enrollee or an enrollee's appointed representative may request a standard or expedited redetermination. An enrollee's prescribing physician may request an expedited redetermination on an enrollee's behalf. If the enrollee's physician is also the enrollee's appointed representative, he or she may also request a standard redetermination. 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 "Related Links Inside CMS" section below. How to Request a Redetermination Redetermination requests must by filed with the plan sponsor within 60 calendar days from the date of the notice of the coverage determination. Expedited requests may be made orally or in writing. Standard requests must be made in writing, unless the enrollee's plan sponsor accepts oral requests (an enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral requests). How a Plan Sponsor Processes Redetermination Requests Once the request is received by the plan sponsor, it must make its decision and notify the enrollee of its decision as quickly as the enrollee's health requires, but no later the 72 hours for expedited requests or 7 calendar days for standard requests after receiving the request. If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a reconsideration by the Independent Review Entity. Use the navigation tool on the left side of this page to link to subpages that contain detailed information about reconsiderations by the Independent Review Entity or any other level of appeal.
Page Last Modified: 01/20/2009 9:01:03 AM
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