tci Medicare Compliance & Reimbursement - 2024 Issue Q1

Reader Questions: Understand How The Part D Appeals Process Works

Question: As a Medicare Part D provider prescriber, our practice was curious about the appeals process for Part D coverage. Is the system the same as other parts of Medicare? AAPC Forum Participant Answer: Yes, and no. There are still five levels of Medicare appeals for Part D similar to traditional fee-for-service (FFS) Medicare. Those five steps include the following basics: 1. Redetermination 2. Reconsideration 3. Hearing by an Administrative Law Judge 4. Review by the Medicare Appeals Council 5. Judicial review by Federal District Court Difference: However, the entity you send your redetermination to as a Part D...

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