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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 provider is different from FFS Medicare. For Medicare Parts A/B, you send your first level of appeal to the Medicare Administrative Contractor (MAC) under which you submitted the claim you鈥檙e appealing. But as a Part D provider, you鈥檇 send your appeal to your Part D plan sponsor. The Centers for Medicare & Medicaid Services (CMS) contracts with nongovernmental entities as Part D plan sponsors.

Additionally, 鈥渋f a Part D plan sponsor issues an unfavorable or partially favorable redetermination decision, the enrollee, the enrollee鈥檚 representative, or the enrollee鈥檚 prescriber may appeal the decision to the Independent Review Entity (IRE),鈥� CMS says in appeals guidance. 鈥淐2C Innovative Solutions, Inc. is the current Part D IRE. or the second level of appeal, reconsideration, [for] Part D providers,鈥� the agency notes.

Under Part D appeals levels three through five, only the enrollee or the enrollee鈥檚 representative may request an appeal from the corresponding entities, but the enrollee鈥檚 subscriber may not request an appeal on their behalf. However, if the enrollee鈥檚 subscriber is also the enrollee鈥檚 representative, they can request the next level of appeal.

Resource: Find more information on Part D appeals at .