People With Medicare
Step 2 - Reconsideration
The second step in the appeals process is asking for what is called "reconsideration." In reconsideration, an organization other than your Part D plan reviews your request for coverage. This organization is called an Independent Review Entity, or IRE. An Independent Review Entity is an agency or organization that Medicare pays to review appeals. The Independent Review Entity is not part of the government or a part of your plan. The current Independent Review Entity for all plans is a company called MAXIMUS.
How much time do I have to ask for reconsideration?
You have 60 calendar days from the time the plan tells you it has denied your redetermination request to ask for reconsideration.
Who can ask for a reconsideration?
You can file for reconsideration yourself, or you can appoint someone to do it for you. Your doctor cannot make a reconsideration request for you.
If you would like to appoint someone to do it for you, you and the person you are appointing should submit Medicare's "Appointment of Representative" form with your reconsideration request.
How do I request a reconsideration?
You must make your reconsideration request in writing. If your plan denies your redetermination request, it should send you a "Request for Reconsideration" form that you can use. You can also get this form online. The redetermination denial letter from your plan should also tell you the address or fax number where you should send your reconsideration request.
How long will it take for the Independent Review Entity to respond to my request?
For standard requests, the Independent Review Entity will tell you the decision 7 calendar days after they receive your request, or sooner. If your doctor tells the Independent Review Entity that your life or your health will be in danger if you have to wait for 7 days, then the Independent Review Entity must tell you the decision within 72 hours.
After I file for reconsideration, what happens next?
If the Independent Review Entity decides in your favor, then you do not need to do anything more.
If the Independent Review Entity decides against you, then you can request a hearing with an Administrative Law Judge.