Use Your Plan: Steps in the Medicare Appeal Process
Step 1: Request
a coverage determination (a formulary exception is one type).
Step 2: Request a redetermination.
Step 3: Request a reconsideration.
Step 4: Appeal to the
Administrative Law Judge (ALJ).
Step 5: Appeal
to the Medicare Appeals Council (MAC).
Step 6: File
suit in Federal District Court.
Step 1: Request a coverage determination. If you are requesting coverage for a medicine that is not on your plan's formulary, you should request a specific type of coverage determination called a formulary exception.
(Download a form you can use to request a formulary exception.
You may need to ask your health care provider for information to complete the form.)
In this step the drug plan makes a formal decision about whether or
not to cover your medication as prescribed.
- Submitting the Request: You, your appointed
representative or your health care provider may make this request verbally
or in writing to your plan. If you are requesting a formulary exception, your plan must receive a statement from your health care provider explaining the medical reason you need the specific drug.
- Timeframe: You may make this request at any time. You can take this step whether
you (1) go ahead and buy the medicine using your own money and want
to be paid back or (2) you walk away without the medicine when you're
told it is not covered.
- Decision: A decision must be made and sent to you
as soon as your clinical condition requires, but no later than 72
hours after your health care provider's statement is received for a routine request or 24 hours for an expedited request.
(An expedited request is granted if your doctor tells your plan that
you may suffer negative health consequences if you do not receive
the medication immediately.)
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Step 2: Request a redetermination.
In this step a doctor at the drug plan who was not involved
in the original denial must review the case again and make a decision.
- Submitting the Request: You or your appointed representative
must make this request in writing to your plan. There is no special
form to use. A simple letter saying that you want to appeal further should be enough.
Your health care provider may not do so unless he or she is your appointed
representative.
- Timeframe: You must request a redetermination within 60 days of receiving an "adverse coverage determination" or a denial of your formulary exception request.
- Decision: A decision must be made and sent to you
as soon as your clinical condition requires, but no later than 7 days
for a routine request or 72 hours for an expedited request.
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Step 3: Request a reconsideration.
In this step an independent agency on contract
to the Medicare agency will review the case and make its own decision.
- Submitting the Request: You or your appointed
representative must make this request in writing to the independent
review entity (IRE). The letter you received in response to your redetermination request
will give you the address and instructions on how to write to the
IRE.
- Timeframe: You must request that this step to be
taken within 60 days of receiving a denial of your redetermination request for coverage.
- Decision: A decision must be made and sent to you
as soon as your clinical condition requires, but no later than 7 days
for a routine request or 72 hours for an expedited request.
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Step 4: Appeal to the
Administrative Law Judge (ALJ).
- Submitting the Request: You or your appointed
representative must make this request in writing. The letter you received in response to your reconsideration request will have further instructions. You may want to have help from a lawyer.
- Timeframe: You must request that this step to be
taken within 60 days of receiving a denial of your reconsideration request for coverage.
- Decision: No time requirement.
- Other Requirements or Notes: To be able to go to
this level of appeal, the projected cost of the drug(s) denied must
meet a dollar amount that is set each year. This is called the "amount
in controversy threshold" ($110 in 2007). Your denied drug costs
include the amount you would pay if you had to pay for all prescribed
refills for the remainder of the calendar year yourself.
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Step 5: Appeal to the
Medicare Appeals Council (MAC).
- Submitting the Request: You or your appointed
representative must make this request in writing. The written decisions you receive from the Administrative Law Judge (ALJ) will have further instructions. You may want to have help from a lawyer. It must be on a form
DAB-101 or must include several pieces of required information.
- Timeframe: You must request that this step to be
taken within 60 days of receiving a denial of your appeal to the ALJ.
- Decision: No time requirement.
- Other Requirements or Notes: To be able to go to
this level of appeal, you must already have appealed to the Administrative
Law Judge.
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Step 6: File suit in
Federal District Court.
- Submitting the Request: You will most likely need help from a lawyer to file
suit in court.
- Timeframe: You must request that this step to be
taken within 60 days of receiving a denial of your appeal to the MAC.
- Decision: There is no specific requirement for
when a decision will be made. It depends on the court schedule.
- Other Requirements or Notes: To be able to go to
this level of appeal, you must already have appealed to the Medicare
Appeals Council, and the projected cost of the drug(s) denied must
be at least $1,130 in 2007. Your denied drug costs include the amount
you would pay if you had to pay for all prescribed refills for the
remainder of the calendar year yourself.
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