Wisconsin Medicare Prescription Drug Plans

Questions? Call 800-731-0459 (TTY: 711)

Plan Complaints, Grievances, and Appeals


What to do if you have complaints

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call our Customer Service at 800-688-1604 (TTY/TDD: 800-716-3231) 24 hours a day, seven days a week. Calls to these numbers are free.

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan customer. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from this Plan or penalized in any way if you make a complaint.

A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. The other sections on this page briefly discuss grievances, coverage determinations, and appeals.

For Quality of Care Complaints, You May Also Complain to the Quality Improvement Organization (QIO)

For Wisconsin, the Quality Improvement Organization (QIO) is KePRO. Complaints concerning the quality of care received under Medicare may be acted upon by the Medicare prescription drug plan under the grievance process, by an independent organization called the QIO, or by both. For example, if an enrollee believes his/her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with the QIO in addition to or in lieu of a complaint filed under the Part D plan's grievance process. For any complaint filed with the QIO, the Part D plan must cooperate with the QIO in resolving the complaint.

How to File a Quality of Care Compliant with the QIO

Quality of care complaints filed with the QIO must be made in writing. An enrollee who files a quality of care grievance with a QIO is not required to file the grievance within a specific time period. To file a quality of care complaint with the QIO you can call 855-408-8557, visit the KePRO website or write to them at:

KePRO
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609

Filing a Complaint with Medicare

You can file a complaint directly with Medicare. You can call 800-Medicare (800-633-4227) 24 hours a day, seven days a week. TTY/TDD users can call 877-486-2048. Calls to these numbers are free.

If you wish to file a complaint without calling, please follow the instructions in the link below.
Medicare Complaint form

To request information about the aggregate number of grievances, appeals, and exceptions filed with the WPS MedicareRx Plan (PDP), please call our Customer Support Department at 800-944-2656 (TTY 711) Monday through Friday, 8 a.m. to 4:30 p.m.

What is a Grievance?

A grievance is any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

You would file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you might file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.

How to File a Grievance

A grievance usually will not involve coverage or payment for Part D prescription drug benefits (concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process found under the Coverage Determinations tab listed above).

In certain cases, you have the right to ask for a "fast grievance," meaning your grievance will be decided within 24 hours. We discuss these fast-track grievances in more detail under asking for a fast decision on the Coverage Determinations tab listed above.

If you have a grievance, we encourage you to first call Customer Service. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the WPS Complaints and Grievances procedure. WPS Complaints and Grievances addresses concerns about the service you have received. For example, you may file a service grievance if you are dissatisfied about the way a staff person has handled your particular issue or with the care you received from your pharmacy.

You may file a service grievance by calling Customer Service at 800-688-1604 (TTY 800-716-3231) 24 hours a day, seven days a week, or by submitting a service complaint and grievance in writing to:
WPS MedicareRx Plan
c/o Express Scripts
ATTN: Service Grievance Resolution Team
P.O. Box 3610
Dublin, OH 43016-0307

Whether you call or write, you should contact Member Services right away because a grievance must be filed with WPS no later than 60 days after the event or incident that brought about the grievance.

The Plan may contact you by phone to resolve your service grievance. If your service grievance is not resolved in five days, you will receive a written acknowledgement that your grievance has been received. If your grievance involves a decision by our Appeals department to deny your request to "expedite" a coverage determination or redetermination, we will respond to you within 24 hours of receipt of your grievance, provided that you have not already purchased or received the drug that is in dispute. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

What is a Coverage Determination?

Whenever you ask for a Part D prescription drug benefit, the first step is called "requesting a coverage determination." When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment. If you request an exception, your doctor must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

How to Request a Coverage Determination

We use the word "provide" in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.

If your doctor or pharmacist tells you that we will not cover a prescription drug, you can contact us and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

  • If you are not getting a prescription drug that you believe may be covered by us.
  • If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of covered drugs (called a "formulary"). You can request an exception to our formulary.
  • If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the copayment/coinsurance we require you to pay for a drug.
  • If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
  • If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation. You can request an exception by requesting that the requirement or limitation be removed.
  • If there is a requirement that you use a generic equivalent of a drug. You can request an exception by requesting that this requirement be removed. You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.
The process for requesting a coverage determination is discussed in greater detail below in the section titled "Detailed information about how to request a coverage determination and an appeal."

Who May Ask for a Coverage Determination?

You can ask us for a coverage determination yourself, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Review Department
P.O. Box 66571
St. Louis, MO 63166-6571
You can also call Customer Service to learn how to name your appointed representative.
Download the Appointment of Representative Form

You may use either of the forms shown below to request an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment or you wish to request a coverage determination. Select the link to one of the forms below and print them out so you can complete the form and send it to us at the addresses shown above.
Medicare Part D Coverage Determination Request Form
Your prescriber can help you request a coverage determination by submitting an electronic request to our prescription benefit manager by visiting the Express Scripts website.

Do You Have a Request for a Part D Prescription Drug That Needs to be Decided More Quickly Than the Standard Timeframe?

A decision about whether we will cover a Part D prescription drug can be a "standard" coverage determination that is made within the standard timeframe (typically within 72 hours) or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called an "expedited coverage determination."

You can ask for a fast decision only if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function, and you have not already received the drug.

Asking for a Standard or a Fast Decision

To ask for a standard or a fast decision, you, your doctor, or your appointed representative should refer to our Customer Service numbers listed below for assistance. You can send a fax request to 877-329-3760, send a written request to:
WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Review Department
8111 Royal Ridge Parkway
P.O. Box 66571
St. Louis, MO 63166-6571
Or you can call us at 800-935-6103; our normal business hours are from 7 a.m. to 6 p.m., CT, Monday through Friday. If you are requesting a decision outside of normal business hours, be sure to call (not fax) us at 800-688-1604 (TTY 800-716-3231), 24 hours a day, seven days a week, and ask for further directions.

If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor's support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72-hour standard timeframe.

What Happens When You Request a Coverage Determination?

What happens, including how soon we must decide, depends on the type of decision.

  • For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received.
    Generally, we will give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules - such as dosage or quantity limits or step therapy requirements), we must make our decision no later than 72 hours after we have received your doctor's "supporting statement," which explains why the drug you are asking for is medically necessary. We must give you our decision within 14 calendar days after we receive your request about payment for a Part D drug that you already received. If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible.
    We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the timeframe explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" on the Appeals tab listed above explains how to file this appeal.
    If we have not given you an answer within 72 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
  • For a fast coverage determination about a Part D drug that you have not received.
    If you get a fast review, we will give you our decision within 24 hours after you or your doctor asks for a fast review—sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor's "supporting statement," which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.
    We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision, under the timeframe explained above. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" on the Appeals tab listed above explains how to file this appeal.
    If we decide you are eligible for a fast review, and we have not responded to you within 24 hours after receiving your request, your request will automatically go to Appeal Level 2 on the Appeals tab listed above, where an independent organization will review your case.
    If we do not grant your or your doctor's request for a fast review, we will give you our decision within the standard 72-hour timeframe discussed above. If we tell you about our decision not to provide a fast review by phone, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review, and will explain that we will automatically give you a fast decision if you get a doctor's support for a fast review.

What Happens if We Decide Completely in Your Favor?

If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

  • For a standard decision about a Part D drug, which includes a request about payment for a Part D drug that you already received.
    We must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we get your doctor's "supporting statement." If you are requesting reimbursement for a drug that you already paid for and received, make payment to you no later than 30 calendar days after we get the request.
  • For a fast decision about a Part D drug that you have not received.
    We must authorize or provide you with the benefit you have requested no later than 24 hours of receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we get your doctor's "supporting statement.

What Happens if We Deny Your Request?

If we deny your request, we will send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against your request. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision.

What is an Appeal?

An appeal is a formal way of asking us to review and change an unfavorable coverage decision that we have made. It is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal is also sometimes referred to as a plan "redetermination." What Kinds of Decisions Can be Appealed?

You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for. You can also appeal if you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny your exception request, you can appeal. A coverage determination, which includes those described in the section titled "Detailed information about how to request a coverage determination and appeal," may be appealed if you disagree with our decision.

Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the coinsurance we require you to pay for the drug.

Who May File Your Appeal of the Coverage Determination?

The rules about who may file an appeal are almost the same as the rules about who may ask for a coverage determination. For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing doctor

How Soon Must You File Your Appeal?

You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline.

To file a standard appeal, you can send the appeal to us in writing at:

WPS MedicareRx Plan
c/o Express Scripts
ATTN: Medicare Clinical Appeals Department
P.O. Box 66588
St. Louis, MO 63166-6588

How Does the Appeals Process Work?

There are five levels to the appeals process. Here are a few things to keep in mind as you read the description of these steps in the appeals process:

  • Moving from one level to the next. At each level, your request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor (giving you some or all of what you have asked for), or it may be completely denied (turned down). If you are unhappy with the decision, there may be another step you can take to get further review of your request. Whether you are able to take the next step may depend on the dollar value of the requested drug or on other factors.
  • Who makes the decision at each level? You make your request for coverage or payment of a Part D prescription drug directly to us. We review this request and make a coverage determination. If our coverage determination is to deny your request (in whole or in part), you can go on to the first level of appeal by asking us to review our coverage determination. If you are still dissatisfied with the outcome, you can ask for further review. If you ask for further review, your appeal is then sent outside of this Plan, where people who are not connected to us conduct the review and make the decision. After the first level of appeal, all subsequent levels of appeal will be decided by someone who is connected to the Medicare program or the federal court system. This will help ensure a fair, impartial decision.
Each appeal level is discussed in greater detail below in the section titled "Detailed information about how to request a coverage determination and an appeal."

Appeal Level 1

Appeal Level 1: Asking us to reconsider our coverage determination. Please call Customer Service if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we get your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.

How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, or authorization of a Part D benefit (that is, a Part D drug that you have not yet received). If your appeal concerns a decision we made about authorizing a Part D benefit that you have not received yet, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination. Please see the discussion under "Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe?" and "Asking for a fast decision."

Getting Information to Support Your Appeal

We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to get and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor's records or opinion to help support your request. You may need to give the doctor a written request to get information.

What if You Want a Fast Appeal?

The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal) by calling our Customer Service numbers at 800-938-6103 (TTY 800-716-3231). Our normal business hours are 7 a.m. to 6 p.m. CT, Monday through Friday. Or you can send a written request to us:

  • In writing:
    WPS MedicareRx Plan
    c/o Express Scripts
    ATTN: Medicare Clinical Appeals Department
    P.O. Box 66588
    St. Louis, MO 63166-6588
  • By fax, at 877-852-4070.
  • By telephone-if it is a fast appeal-at 800-688-1604.
You also have the right to ask us for a copy of information regarding your appeal.

Our normal business hours are from 7 a.m. - 8 p.m. central time, Monday through Friday. If you are requesting a fast decision outside of normal business hours, be sure to call (not fax) us at 800-688-1604 (TTY 800-716-3231) 24 hours a day, seven days a week for further directions. Be sure to ask for a "fast," "expedited," or "72-hour" review.

How Soon Must We Decide on Your Appeal?

How quickly we decide on your appeal depends on the type of appeal:

  • For a standard decision about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received.
    After we get your appeal, we have up to seven calendar days to give you a decision but will make it sooner if your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
  • For a fast decision about a Part D drug that you have not received.
    After we get your appeal, we have up to 72 hours to give you a decision, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

What Happens Next if We Decide Completely in Your Favor?

  • For a decision about reimbursement for a Part D drug you already paid for and received.
    We must send payment to you no later than 30 calendar days after we get your request to reconsider our coverage determination.
  • For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for as quickly as your health requires, but no later than seven calendar days after we get your appeal.
  • For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours of receiving your appeal or sooner, if your health would be affected by waiting this long.

What Happens Next if We Deny Your Appeal?

If we deny any part of your appeal, you or your appointed representative has the right to ask an independent organization to review your case. This IRE contracts with the federal government and is not part of our Plan.

Appeal Level 2

Appeal Level 2: If we deny any part of your first appeal, you may ask for a review by a government-contracted independent review entity (IRE).

What IRE Does This Review?

At the second level of appeal, your appeal is reviewed by an outside, IRE that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this organization.

How Soon Must You File Your Appeal?

You or your appointed representative must make a request for review by the IRE in writing within 60 calendar days after the date you were notified of the decision on your first appeal. You must send your written request to the IRE whose name and address are included in the redetermination notice you get from us.

What if You Want a Fast Appeal?

The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination, except your prescribing doctor cannot file the request for you—only you or your appointed representative may file the request. If you want to ask for a fast appeal, please follow the instructions under "Asking for a fast decision." Remember that if your prescribing doctor provides a written or oral supporting statement explaining that you need the fast appeal, the IRE will automatically treat you as eligible for a fast appeal.

How Soon Must the Independent Review Entity Decide?

After the IRE gets your appeal, how long the organization can take to make a decision depends on the type of appeal:

  • For a standard request about a Part D drug, which includes a request about reimbursement for a Part D drug that you already paid for and received, the IRE has up to seven calendar days from the date it gets your request to give you a decision.
  • For a fast decision about a Part D drug that you have not received, the IRE has up to 72 hours from the time it gets the request to give you a decision.

If the Independent Review Entity Decides Completely in Your Favor:

The IRE will tell you in writing about its decision and the reasons for it. What happens next depends on the type of appeal:

  • For a decision about reimbursement for a Part D drug you already paid for and received.
    We must pay within 30 calendar days from the date we get notice reversing our coverage determination. We will also send the IRE a notice that we have abided by its decision
  • For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we get notice reversing our coverage determination. We will also send the IRE a notice that we have abided by its decision.
  • For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we get notice reversing our coverage determination. We will also send the IRE a notice that we have abided by its decision.

What Happens Next if the Review Organization Decides Against You (Either Partly or Completely)?

The IRE will tell you in writing about its decision and the reasons for it. You or your appointed representative may continue your appeal by asking for a review by an ALJ (see Appeal Level 3), provided that the dollar value of the contested Part D benefit is $160 or more in 2018.

Appeal Level 3

Appeal Level 3: If the organization that reviews your case in Appeal Level 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge (ALJ).

As stated above, if the IRE does not rule completely in your favor, you or your appointed representative may ask for a review by an ALJ. You must make a request for review by an ALJ in writing within 60 calendar days after the date of the decision made at Appeal Level 2. You may request that the ALJ extend this deadline for good cause. You must send your written request to:

Office of Medicare Hearings and Appeals
Central Office
200 Public Square, Suite 1260
Cleveland, OH 44114
Phone: 866-941-7012
Medicare Part D
Requests for expedited hearings may be made orally or in writing.
Tips for Filing a Request for ALJ Hearing

The form to request a hearing can be found on the Office of Medicare Hearings and Appeals official website. Select the link titled "Request or Waive an Administrative Law Judge Hearing with OMHA".

You, your chosen representative (if any), and the local agency will receive written notice of the scheduled time, date, and place of the hearing at least 20 days before the fair hearing. A hearing will generally be held by video-teleconference (VTC). However, an in-person hearing may be held if the ALJ determines the circumstances of the appeal warrant an in-person hearing. Telephone hearings may also be arranged in certain circumstances for the convenience of the parties. There are also cases in which the issues are decided solely on the documentary evidence and without an oral hearing. This is called an on-the-record decision.

During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or getting the file in person when feasible), and be represented by counsel. The ALJ will not review your appeal if the dollar value of the requested Part D benefit does not meet a certain dollar threshold requirement. This dollar amount may change each year. For calendar year 2018, the amount in controversy threshold is $160.

How is the Dollar Value (The "Amount Remaining in Controversy") Calculated?

If we have refused to provide Part D prescription drug benefits, the dollar value for requesting an ALJ hearing is based on the projected value of those benefits. The projected value includes any costs you could incur based on the number of refills prescribed for the requested drug during the plan year. Projected value includes your copayments, all costs incurred after your costs exceed the initial coverage limit, and costs paid by other entities.

You may also combine multiple Part D claims to meet the dollar value if:

  • The claims involve the delivery of Part D prescription drugs to you;
  • All of the claims have received a determination by the IRE as described in Appeal Level 2;
  • Each of the combined requests for review are filed in writing within 60 calendar days after the date that each decision was made at Appeal Level 2; and
  • Your hearing request identifies all of the claims to be heard by the ALJ.

How Soon Does the Judge Make a Decision?

The ALJ will hear your case, weigh all of the evidence up to this point, and make a decision as soon as possible.

If the Judge Decides in Your Favor:

The ALJ will tell you in writing about his or her decision and the reasons for it. What happens next depends on the type of appeal:

  • For a decision about payment for a Part D drug you already received.
    We must send payment to you no later than 30 calendar days from the date we get notice reversing our coverage determination.
  • For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we get notice reversing our coverage determination.
  • For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we get notice reversing our coverage determination.

If the Judge Rules Against You:

You have the right to appeal this decision by asking for a review by the Medicare Appeals Council (MAC) Appeal Level 4. The letter you get from the ALJ will tell you how to request this review.

Appeal Level 4

Appeal Level 4: Your case may be reviewed by the Medicare Appeals Council (MAC). The MAC will first decide whether to review your case. There is no minimum dollar value for the MAC to hear your case. If you recieved a denial at Appeal Level 3, you or your appointed representative can request review by filing a written request with the Council.

This is a form that you may use to request your review by the MAC.
Request for Review of Administrative Law Judge Medicare Decision

The MAC does not review every case. When it gets your case, it will first decide whether to review your case. If they decide not to review your case, then you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice advising you of any action taken with respect to your request for review. The notice will tell you how to request a review by a Federal Court Judge.

How Soon Will the Council Make a Decision?

If the MAC reviews your case, they will make their decision as soon as possible.

If the Council Decides in Your Favor:

The MAC will tell you in writing about its decision and the reasons for it. What happens next depends on the type of appeal:

  • For a decision about payment for a Part D drug you already received.
    We must send payment to you no later than 30 calendar days from the date we get notice reversing our coverage determination.
  • For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we get notice reversing our coverage determination.
  • For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we get notice reversing our coverage determination.

If the Council Decides Against You:

In 2018 if the amount involved is $1,560 or more, you have the right to continue your appeal by asking a Federal Court Judge to review the case (Appeal Level 5). The letter you get from the Medicare Appeals Council will tell you how to request this review. If the value is less than $1,560, the Council's decision is final and you may not take the appeal any further.

Appeal Level 5

Appeal Level 5: Your case may go to a Federal Court In order to request judicial review of your case; you must file a civil action in a United States district court. The letter you get from the MAC in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether to review your case.

How Soon Will the Judge Make a Decision?

The Federal judiciary is in control of the timing of any decision.

If the Judge Decides in Your Favor:

Once we get notice of a judicial decision in your favor, what happens next depends on the type of appeal:

  • For a decision about payment for a Part D drug you already received.
    We must send payment to you within 30 calendar days from the date we get notice reversing our coverage determination.
  • For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we get notice reversing our coverage determination.
  • For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we get notice reversing our coverage determination.

If the Judge Decides Against You:

The Judge's decision is final and you may not take the appeal any further.

 

This page last modified Monday, 16-Apr-2018 15:31:14 CDT

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