The Level 2 claim appeals process differs based on what Part of Medicare you want to appeal. If you are dissatisfied with the outcome of your Level 1 appeal (called a redetermination in Medicare Part D), you may file a Level 2 appeal. The Level 2 appeal is called a "reconsideration".
Who Conducts Level 2 Appeals
- An Independent Review Entity (IRE), retained by CMS, will conduct the Level 2 appeal.
- IREs have their own physicians and other health professionals to independently review and assess the medical necessity of the prescriptions and items pertaining to your case.
- The IRE will take into consideration the views of your prescribing physician.
Time Limit for Filing a Level 2 Appeal (e.g., "Request for a reconsideration")
- File a Level 2 written appeal within 60 days of receiving the notice of redetermination. The notice of redetermination was mailed to you and contains the Level 1 appeal decision.
- You will file your request with the IRE named on the notice of redetermination.
For more information about filing a Level 2 appeal, visit the "Claims & Appeals" section of Medicare.gov.
When you Will Get a Response to Your Appeal
- In most cases, you will receive notice (called "Notice of Reconsideration Determination") of the IRE's decision within 7 days after submitting your request for a reconsideration.
- The notice will contain detailed instructions about your right to appeal to OMHA (Level 3) if you are dissatisfied with the IRE’s decision.
Special Circumstances
You may request an expedited reconsideration for Part D coverage decisions. Your request will be expedited if the Independent Review Entity (IRE) determines or your doctor tells the IRE that your life or health will be seriously jeopardized by waiting for a standard decision. If your request is expedited, the IRE has 72 hours to notify you of its decision.
Appealing to the Next Level of Appeals
If your Level 2 appeal was not decided in your favor and you disagree with the decision, you may file a Level 3 appeal with OMHA if the remaining amount in controversy is $170 or more (2020). Note you may be able to combine claims to meet the minimum dollar amount. You have 60 days after receiving the Level 2 decision to request a Level 3 hearing in writing.
Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.
