Appeals Process
- What is an appeal?
- How to request an appeal
- Appeal Level 1: Request for Redetermination
- Appeal Level 2: Independent Review Organization
- Appeal Level 3: Administrative Law Judge
- Appeal Level 4: Medicare Appeals Council
- Appeal Level 5: Federal Court
An appeal 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.
If you are unhappy or disagree with a coverage determination, you can ask for an appeal. You can generally appeal our decision not to cover a drug, vaccine or other Part D benefit. You can 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.
Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment we require you to pay for the drug.
There are five levels to the appeals process. At each level, your request for Part D prescription drug 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.
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 Elderplan 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.
Appeal Level 1: Request for Redetermination
If we deny all or part of your request in our coverage determination, you may ask us to reconsider our decision. This is called an “appeal” or “request for redetermination.”
Please call us at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220), 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 receive 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.
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 obtain 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.
You can give us your additional information in any of the following ways:
- In writing, to: Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220 - By fax, at (718) 491-7226
- By telephone—if it is a fast appeal—at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220).
- In person, at: Elderplan, Inc.
6323 Seventh Avenue
Brooklyn, NY 11220
You also have the right to ask us for a copy of information regarding your appeal. You can call us at 1-800-353-3765,
8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220), or write to us at:
Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220
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 physician.
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:
Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220
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 us at 1-800-353-3765, 8 a.m.–8 p.m., 7 days a week (for TTY, call 1-800-662-1220). Or, you can deliver a written request to:
Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220
Or fax it to (718) 491-7226. Be sure to ask for a “fast,” “expedited,” or “72-hour” review.
Remember that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast 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, we have up to 7 calendar days to give you a decision after we receive your appeal. We will give you a decision more quickly if your health condition requires us to. If we do not give you our decision within 7 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, we have up to 72 hours to give you a decision after we receive your appeal. We will give you a quicker decision 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 receive 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 7 calendar days after we received 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 have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and is not part of Elderplan.
Appeal Level 2: Independent Review Organization
If we deny any part of your first appeal, you may ask for a review by a government-contracted independent review organization. At the second level of appeal, your appeal is reviewed by an outside, independent review organization that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The independent review organization 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.
You or your appointed representative must make a request for review by the independent review organization 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 independent review organization whose name and address is included in the redetermination you receive from Elderplan.
If you want a fast appeal, the rules are the same as the rules about asking for a fast coverage determination, except your prescribing physician cannot file the request for you—only you or your appointed representative may file the request. Remember that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, the independent review organization will automatically treat you as eligible for a fast appeal.
After the independent review organization receives 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 independent review organization has up to 7 calendar days from the date it received your request to give you a decision.
- For a fast decision about a Part D drug that you have not received, the independent review organization has up to 72 hours from the time it receives the request to give you a decision.
If the independent review organization decides completely in your favor, the independent review organization 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 send payment to you within 30 calendar days from the date we receive notice reversing our coverage determination. We will also send the independent review organization 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 receive notice reversing our coverage determination. We will also send the independent review organization 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 receive notice reversing our coverage determination. We will also send the independent review organization a notice that we have abided by its decision.
If the review organization decides against you (either partly or completely), the independent review organization 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 Administrative Law Judge (see Appeal Level 3), provided that the dollar value of the contested Part D benefit is more than the minimum requirement.
Appeal Level 3: Administrative Law Judge
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.
As stated above, if the independent review organization does not rule completely in your favor, you or your appointed representative may ask for a review by an Administrative Law Judge. You must make a request for review by an Administrative Law Judge in writing within 60 calendar days after the date of the decision made at Appeal Level 2. You may request that the Administrative Law Judge extend this deadline for good cause. You must send your written request to:
Elderplan, Inc.
Grievances and Appeals Department
6323 Seventh Avenue
Brooklyn, NY 11220
We will forward your request to the Administrative Law Judge on your behalf.
During the Administrative Law Judge review, you may present evidence, review the records (by either receiving a copy of the file or accessing the file in person when feasible) and be represented by counsel. The Administrative Law Judge will not review your appeal if the dollar value of the requested Part D benefit is less than the required minimum. If the dollar value is less than the required minimum, you may not appeal any further.
If we have refused to provide Part D prescription drug benefits, the dollar value for requesting an Administrative Law Judge 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 co-payments, all expenditures incurred after your expenditures exceed the initial coverage limit and expenditures 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 independent review organization 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 Administrative Law Judge.
How soon does the Administrative Law Judge make a decision? The Administrative Law Judge will hear your case, weigh all of the evidence up to this point and make a decision as soon as possible.
If the Administrative Law Judge decides in your favor, he or she 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 receive 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 receive 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 receive notice reversing our coverage determination.
If the Administrative Law Judge rules against you, you have the right to appeal this decision by asking for a review by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Administrative Law Judge will tell you how to request this review.
Appeal Level 4: Medicare Appeals Council
The Medicare Appeals Council will first decide whether to review your case. There is no minimum dollar value for the Medicare Appeals Council to hear your case. If you got a denial at Appeal Level 3, you or your appointed representative can request review by filing a written request with the Council.
The Medicare Appeals Council does not review every case it receives. When it gets your case, it will first decide whether or not 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 Medicare Appeals Council 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 Medicare Appeals Council reviews your case, it will make its decision as soon as possible.
If the Council decides in your favor, the Medicare Appeals Council 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 receive 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 receive 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 receive notice reversing our coverage determination.
If the Council decides against you and the amount involved is more than the required minimum, 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 the required minimum, the Council’s decision is final and you may not take the appeal any further.
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 Medicare Appeals Council in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether or not to review your case. If the contested amount is more than the required minimum, you may ask a Federal Court Judge to review the case.
How soon will the Federal Court Judge make a decision? The Federal judiciary is in control of the timing of any decision.
If the Federal Court Judge decides in your favor, we will receive notice of a judicial decision. 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 receive 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 receive 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 receive notice reversing our coverage determination.
If the Federal Court Judge decides against you, the Judge’s decision is final and you may not take the appeal any further.
