Review by Part C Independent Review Entity (IRE)
Guidance for if a Medicare Advantage (Part C) health plan makes an adverse reconsideration decision (upholds its initial adverse organization determination), the plan must automatically submit the case file and its decision for review by the Part C Independent Review Entity (IRE).
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 24, 2020
If a Medicare Advantage (Part C) health plan makes an adverse reconsideration decision (upholds its initial adverse organization determination), the plan must automatically submit the case file and its decision for review by the Part C Independent Review Entity (IRE). For more information about the Part C IRE, see Section 70 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the “Downloads” section below.
Currently, MAXIMUS Federal Services is the Part C IRE. For additional information about MAXIMUS' reconsideration process, click on the MAXIMUS Federal Services link in the “Related Links” section below.
Fact Sheets: Part C Reconsideration Appeals Data
These reports summarize and highlight key Part C IRE reconsideration data from January 1, 2016 to the most recently available date.
To view the Fact Sheets, click on the link in the "Downloads" section below.
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.