Medicare Prescription Drug Review by the Medicare Appeals Council
Guidance for the enrollee or the enrollee's representative may appeal the decision by requesting a review by the Medicare Appeals Council (Appeals Council) if the Office of Medicare Hearings and Appeals (OMHA) Administrative Law Judge (ALJ) or attorney adjudicator issues an adverse decision.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 08, 2020
If an Office of Medicare Hearings and Appeals (OMHA) Administrative Law Judge (ALJ) or attorney adjudicator issues an adverse decision, the enrollee or the enrollee's representative may appeal the decision by requesting a review by the Medicare Appeals Council (Appeals Council).
An enrollee's prescriber may not request a review by the Appeals Council on an enrollee's behalf unless the enrollee's prescriber is also the enrollee's appointed representative.
For more information about appointing a representative, see section 20 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, found in the "Downloads" section below.
How to Request a Review by the Appeals Council
Requests for standard reviews must be made in writing, which includes by fax. Requests for expedited reviews may be made verbally or in writing. The request must be filed with the Appeals Council within 60 calendar days from the date of OMHA's decision notice. The request may be made on Appeal Form DAB-101, which can be obtained by clicking on the link in "Related Links" section below.
If the Appeals Council's decision is unfavorable, the decision will contain the information needed to file a request for review by a Federal District Court.
For more information about how to request a review with the Appeals Council, you may click on the link to the Medicare Appeals Council's website in the "Related Links" section below, or see section 70 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the "Downloads" section below.
Detailed information about review by a Federal District Court, or any other level of appeal, can be found using the left navigation menu on this page.
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.