Medicare Compliance & Reimbursement

1. Redetermination

2. Reconsideration

3. Hearing by an Administrative Law Judge

4. Review by the Medicare Appeals Council

5. Judicial review by Federal District Court

Difference: However, the entity you send your redetermination to as a Part D provider is different from FFS Medicare. For Medicare Parts A/B, you send your first level of appeal to the Medicare Administrative Contractor (MAC) under which you submitted the claim you’re appealing. But as a Part D provider, you’d send your appeal to your Part D plan sponsor. The Centers for Medicare & Medicaid Services (CMS) contracts with nongovernmental entities as Part D plan sponsors.

Additionally, “if a Part D plan sponsor issues an unfavorable or partially favorable redetermination decision, the enrollee, the enrollee’s representative, or the enrollee’s prescriber may appeal the decision to the Independent Review Entity (IRE),” CMS says in appeals guidance. “C2C Innovative Solutions, Inc. is the current Part D IRE. or the second level of appeal, reconsideration, [for] Part D providers,” the agency notes.

Under Part D appeals levels three through five, only the enrollee or the enrollee’s representative may request an appeal from the corresponding entities, but the enrollee’s subscriber may not request an appeal on their behalf. However, if the enrollee’s subscriber is also the enrollee’s representative, they can request the next level of appeal.

Resource: Find more information on Part D appeals at www.cms.gov/medicare/appeals-grievances/prescription-drug.