Medicare Appeals Procedures
If an ALJ issued a decision or dismissal for a claim for Part D drugs, other than a claim solely for payment of Part D drugs already furnished, an enrollee may request that his or her request for review be expedited. If you wish to expedite review, these procudures apply to your appeal:
If you do not agree with the Administrative Law Judge’s (ALJ’s) decision or dismissal, you may appeal to the Medicare Appeals Council (MAC). We call an appeal to the MAC a “request for review.” The MAC will issue a decision, dismissal order or remand within 90 calendar days of receiving the request for review, unless the timeframe is extended. Upon receipt of the ALJ’s written decision or dismissal, the enrollee may request that the MAC review be expedited if the Part D drug has not already been furnished and the enrollee’s prescribing physician (or other prescriber) indicates or the MAC determines that the standard timeframe may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function.
Timeframe for an Enrollee to File a Request for Expedited Review:
A request for expedited review must be received by the MAC within 60 days after you receive ALJ’s written decision or dismissal. The MAC will assume that you received the ALJ’s decision or dismissal five days after the date shown on it, unless you show that you received it later. If you file the appeal late, you must show that you had good cause.
An enrollee may request that his or her claim be expedited by calling the MAC at 1-866-365-8204. You should be prepared to provide the following:
- the enrollee’s name and health insurance claim number;
- the ALJ appeal number;
- the date of the ALJ’s written decision or dismissal;
- the enrollee’s telephone number;
- whether the claim is solely for payment of Part D drugs already furnished;
- whether the prescribing physician (or other prescriber) has indicated that any delay in receiving the Part D drug may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function, and
- whether this information was previously submitted at the lower levels of appeal,
- the telephone number of the prescribing physician or prescriber;
- whether the enrollee’s claim has been expedited at the lower levels of appeal.
An enrollee may file a written request for expedited review:
You may use the form DAB-101 to request expedited review by marking the “Yes” box for Line 9.
Mail the form and a copy of the ALJ decision or dismissal to:
Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Ave., S.W.
Cohen Building, Room G-644
Washington, D.C. 20201
Or you may fax the request to (202) 565-0227. If you send a fax, please do not also mail a copy.
The Medicare regulations at 42 C.F.R. Part 423, Subpart U, apply to this case. An enrollee may appoint an attorney or other person to represent him or her. Legal aid groups may provide legal services at no charge.
Medicare Appeals Council Action
The MAC may deny or grant the request for expedited review.
If the MAC grants the request, the enrollee will promptly be notified by phone and the MAC will issue its final decision, dismissal order, or remand as expeditiously as the enrollee’s health condition requires but no later than 10 calendar days after the request for expedited review was received.
If the MAC denies the request for expedited review, the MAC will give the enrollee written notice of the denial within five calendar days of the request for expedited review and thereafter will issue a final decision, dismissal order, or remand within 90 calendar days from when the request was received. The denial of the request for expedited review is not appealable.