How To Request Informal Written Reconsideration - New 04/08/2008
This document includes information about the following:
- What are the three levels of appeals?
- What is an initial determination?
- What if I disagree with the adverse initial determination made by CMS' RDS Center?
- When can I make a request for informal written reconsideration?
- Can I make a request for informal written reconsideration after the 15 calendar day deadline has passed?
- Who may request an informal written reconsideration on behalf of the Plan Sponsor?
- What happens if the person in the role of Account Manager or Authorized Representative changes after a request for informal written reconsideration is made?
- How do I submit a request for informal written reconsideration?
- If I submit a request for informal written reconsideration for one application, can I submit a separate request for informal written reconsideration for another application?
- How do I know that the request for informal written reconsideration has been received by CMS' RDS Center?
- How do I view an appeals summary?
- How do I submit additional documentary evidence?
- How do I know that the additional documentary evidence has been received?
- Will all requests for informal written reconsideration be reviewed?
- How will CMS' RDS Center process my request for informal written reconsideration?
- How will I know that a decision has been made regarding my request for informal written reconsideration?
- What steps should I take if the request for informal written reconsideration is approved?
- What if I am dissatisfied with the CMS' RDS Center reconsideration decision?
- Can a request for informal written reconsideration be withdrawn?
- How do I withdraw a previously submitted request for informal written reconsideration?
- What are the appeal statuses?
What are the three levels of appeals?
The following is a brief description of the three levels in the RDS appeal process. Additional information regarding this process can be found in Federal regulations at 42 CFR §423.890.
Informal Written Reconsideration: First level of appeal
A Plan Sponsor is entitled to an informal written reconsideration of an adverse initial determination. This request should be made through the RDS Secure Web Site. This request must be made by the Plan Sponsor within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the adverse initial determination. The request for reconsideration must specify the findings or issues with which the Plan Sponsor disagrees and the reasons for the disagreements. The request for reconsideration may include additional documentary evidence the Plan Sponsor wishes CMS' RDS Center to consider. In conducting the reconsideration, CMS' RDS Center reviews the determination, the evidence and findings upon which it was based, and any other written evidence submitted by the Plan Sponsor before notice of the reconsidered determination is made. CMS' RDS Center will notify the Plan Sponsor by e-mail of the decision. A reconsideration decision is final and binding unless a request for hearing is filed in accordance with Federal regulations at 42 CFR §423.890(b).
Informal Hearing: Second level of appeal
A Plan Sponsor dissatisfied with CMS' RDS Center's reconsideration decision is entitled to an informal hearing with the CMS Hearing Officer. This request for an informal hearing must be made in writing and filed with the CMS Hearing Officer within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the reconsideration decision. The request for an informal hearing must include a copy of CMS' RDS Center's reconsideration decision and must specify the findings or issues in the decision with which the Plan Sponsor disagrees and the reasons for the disagreements. CMS will provide written notice of the time and place of the informal hearing at least 10 days before the scheduled date. The hearing is conducted by the CMS Hearing Officer who neither receives testimony nor accepts any new evidence that was not presented with the reconsideration request. The CMS Hearing Officer decides the case and sends a written decision to the Plan Sponsor, explaining the basis for the decision. The CMS Hearing Officer's decision is final and binding, unless the decision is reversed or modified by the CMS Administrator in accordance with Federal regulations at 42 CFR §423.890(c).
Administrative Review: Third level of appeal
A Plan Sponsor that has received the CMS Hearing Officer's decision upholding CMS' RDS Center's initial or reconsidered determination may request review by the CMS Administrator within 15 days of receipt of the CMS Hearing Officer's decision. The CMS Administrator may review the CMS Hearing Officer's decision. The CMS Administrator's determination is final and binding.
Please Note: The CMS Hearing Officer and CMS Administrator reviews are both independent of CMS' RDS Center. These independent reviews and the procedures for those reviews are not determined by CMS' RDS Center and are not discussed in this document.
What is an initial determination?
An initial determination is a decision made by CMS' RDS Center in response to information that the Plan Sponsor submitted. An initial determination is final and binding unless reconsidered in accordance with Federal regulations at 42 CFR §423.890(a).
Examples of appealable initial determinations are:
Did not meet application deadline:
A Plan Sponsor's valid initial online application or valid initial retiree list was not submitted to CMS' RDS Center by the application deadline. For information about the application deadline, including what is required to be submitted by the application deadline, go to: Important Application Deadline Information.
Reconciliation Final Payment:
A Plan Sponsor does not agree with the amount of the final payment determination made by CMS' RDS Center. The final payment determination is made after Step 12: Review and Submit Reconciliation Payment Request is completed for an application and the application is in "Reconciliation Request Completed" status.
What if I disagree with the adverse initial determination made by CMS' RDS Center?
A Plan Sponsor may request an informal written reconsideration through the RDS Secure Web Site when it disagrees with the adverse initial determination made by CMS' RDS Center. This request must be made by the Plan Sponsor within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the adverse initial determination.
A Plan Sponsor may submit additional documentary evidence for CMS' RDS Center to consider. Please include a documentary evidence cover sheet that specifies your application number. A Sample Supporting Documentary Evidence Cover Sheet (pdf, 20.5kb) has been provided for your convenience.
An example of when informal written reconsideration may be requested:
An application is denied for failure to meet the application deadline, but the Plan Sponsor believes that the valid initial online application and valid initial retiree list were submitted before the application deadline and the denial might be due to a processing error.
When can I make a request for informal written reconsideration?
An informal written reconsideration request must be made by the Plan Sponsor within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the adverse initial determination.
Can I make a request for informal written reconsideration after the 15 calendar day deadline has passed?
If the request for informal written reconsideration is not made within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the adverse initial determination, the informal written reconsideration request is considered invalid and therefore will not be reviewed by CMS' RDS Center.
Who may request an informal written reconsideration on behalf of the Plan Sponsor?
The Account Manager, Authorized Representative, or Designee with Appeal privilege may request an informal written reconsideration on behalf of the Plan Sponsor.
What happens if the person in the role of Account Manager or Authorized Representative changes after a request for informal written reconsideration is made?
A Plan Sponsor is required to have an active Account Manager and an active Authorized Representative. Notifications about the status of the informal written reconsideration are sent through e-mail to the current Account Manager and the current Authorized Representative, which requires updated and valid information. This information must be updated in the RDS Secure Web Site. For more information, go to: How To Reassign Account Managers and Authorized Representatives.
How do I submit a request for informal written reconsideration?
- Log into the RDS Secure Web Site.
- The Plan Sponsor List With Application Summary page displays.
- Select the appropriate Plan Sponsor ID link. The Application List page displays.
- From the Application List page, find the Application Number corresponding to the application you wish to request informal written reconsideration. Select Request Reconsideration from the Actions dropdown and select Go.
- The Request Informal Written Reconsideration: Select Determination page displays. Select the adverse initial determination you would like to appeal and select Continue. Select Cancel to return to the Application List page.
- The Request Informal Written Reconsideration: Days Since Determination page displays.
- Refer to the "sent" date on the e-mail notification of the adverse initial determination. Is the "sent" date within 15 calendar days of today's date?
If you select Yes and select Continue, the Request Informal Written Reconsideration: Explanation page displays. If you select Cancel you will return to the Request Informal Written Reconsideration: Select Determination page.
- In the text box provided on the Request Informal Written Reconsideration: Explanation page, enter the reason for your request. Select the checkbox if you intend to send additional documentary evidence to CMS' RDS Center. To submit, select Submit Reconsideration. Select Cancel to return to the Request Informal Written Reconsideration: Days Since Determination page.
- The Request Informal Written Reconsideration Verification page displays. Select Confirm to submit your request for informal written reconsideration. Select Cancel to return to the previous page.
- The Request Informal Written Reconsideration Confirmation page displays. Select the link if you need to download the Sample Supporting Documentary Evidence Cover Sheet (pdf, 20.5kb). A new window in Adobe Acrobat format will display and not affect you continuing with your application. Select Continue to proceed to the Application List page.
If I submit a request for informal written reconsideration for one application, can I submit a separate request for informal written reconsideration for another application?
Yes. Each informal written reconsideration request is made at the application level.
How do I know that the request for informal written reconsideration has been received by CMS' RDS Center?
The Account Manager, Authorized Representative, and Designee with Appeal privilege will receive an acknowledgement e-mail from CMS' RDS Center following the receipt of the request for informal written reconsideration.
How do I view an appeals summary?
- Log into the RDS Secure Web Site.
- The Plan Sponsor List With Application Summary page displays.
- Select the appropriate Plan Sponsor ID link. The Application List page displays.
- From the Application List page, find the Application Number for the appeal you wish to view. To view the appeal, select Appeal Summary from the Actions dropdown and select Go.
- The Appeal Summary page displays. Locate the Appeal you wish to view and select View/Withdraw Appeal from the Actions column.
- The Appeal Detail page displays. Select Continue to return to the Appeal Summary page.
How do I submit additional documentary evidence?
A Plan Sponsor should request an informal written reconsideration using the RDS Secure Web Site. After the informal written reconsideration is requested, a Plan Sponsor may submit additional documentary evidence for CMS' RDS Center to consider. Please include a documentary evidence cover sheet that specifies your application number. A Sample Supporting Documentary Evidence Cover Sheet (pdf, 20.5kb) has been provided for your convenience. Submit the documentary evidence along with the completed cover sheet to:
Retiree Drug Subsidy Center
Attn: Reconsiderations
PO Box 5060
New York, N.Y. 10274-5060
How do I know that the additional documentary evidence has been received?
The Account Manager, Authorized Representative, and Designee with Appeal privilege will receive an acknowledgement e-mail from CMS' RDS Center following the receipt of additional documentary evidence.
Will all requests for informal written reconsiderations be reviewed?
All timely informal written reconsideration requests will be reviewed by CMS' RDS Center.
How will CMS' RDS Center process my request for informal written reconsideration?
Generally, informal written reconsiderations are processed in the order in which they are received.
In conducting the reconsideration, CMS reviews the determination, the evidence and findings upon which it was based, and any other written evidence submitted by the Plan Sponsor or by CMS before notice of the reconsidered determination is made.
Plan Sponsors should keep in mind, the Appeal Summary page will indicate any status change to the informal written reconsideration request. For more information go to: How do I view an appeals summary? within this document.
How will I know that a decision has been made regarding my request for informal written reconsideration?
The Account Manager, Authorized Representative, or Designee with Appeal privilege will receive an e-mail from CMS' RDS Center indicating the decision.
The Appeal History page will also indicate any status change to the application. For more information go to: How do I view an appeals summary? and What are the appeal statuses? within this document.
What steps should I take if the request for informal written reconsideration is approved?
If further action is required on behalf of the Plan Sponsor, the Plan Sponsor will be notified by CMS' RDS Center.
What if I am dissatisfied with the CMS' RDS Center reconsideration decision?
A Plan Sponsor dissatisfied with the CMS' RDS Center reconsideration decision is entitled to an informal hearing as specified in Federal regulations at 42 CFR §423.890(b). A request for informal hearing must be made in writing and filed with the CMS Hearing Officer within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates CMS' RDS Center reconsideration decision.
Can a request for informal written reconsideration be withdrawn?
Yes. The Plan Sponsor may withdraw an informal written reconsideration request electronically through the RDS Secure Web Site. For more information, go to: How do I withdraw a previously submitted informal written reconsideration? within this document.
How do I withdraw a previously submitted request for informal written reconsideration?
- Log into the RDS Secure Web Site.
- The Plan Sponsor List With Application Summary page displays.
- Select the appropriate Plan Sponsor ID link. The Application List page displays.
- From the Application List page, find the Application Number corresponding to the appeal you wish to withdraw. To withdraw the appeal, select Appeal Summary from the Actions dropdown and select Go.
- The Appeal Summary page displays. Locate the Appeal you wish to view and select View/Withdraw Appeal from the Actions column.
- The Appeal Detail page displays. This page allows you to withdraw an appeal. Select Withdraw Appeal to proceed.
- The Appeal Withdrawal Verification page displays. Select Confirm to withdraw the appeal. Select Cancel to return to the Appeal Detail page.
- The Appeal Withdrawal Confirmation page displays. Print this page for your records. Select Continue to return to the Appeal Summary page.
What are the appeal statuses?
The application appeal statuses are "Reconsideration Requested", "Appeal Under Review", "Approved", "Denied", "Invalid", "Pending" and "Withdrawn".
"Reconsideration Requested": CMS' RDS Center has received a Plan Sponsor's request for informal written reconsideration. If a Plan Sponsor wishes to submit additional documentary evidence for CMS' RDS Center to consider, they should submit such documentation immediately. Please include a documentary evidence cover sheet that specifies your application number. A Sample Supporting Documentary Evidence Cover Sheet (pdf, 20.5kb) has been provided for your convenience.
"Appeal Under Review": CMS' RDS Center is currently reviewing the Plan Sponsor's request for informal written reconsideration. If the Plan Sponsor wishes to submit additional documentary evidence for consideration, they should contact the RDS Help Line immediately to ensure that this additional documentary evidence is received and reviewed before the decision is made.
"Approved": CMS' RDS Center has reviewed the Plan Sponsor's request for informal written reconsideration and reversed the adverse initial determination. If further action is required on behalf of the Plan Sponsor, the Plan Sponsor will be notified by CMS' RDS Center.
"Denied": CMS' RDS Center has reviewed the Plan Sponsor's request for informal written reconsideration and upheld the adverse initial determination. A Plan Sponsor dissatisfied with the CMS' RDS Center reconsideration decision is entitled to an informal hearing as specified in Federal regulations at 42 CFR §423.890(b). This request for an informal hearing must be made in writing and filed with the CMS Hearing Officer within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates CMS' RDS Center reconsideration decision.
"Invalid": The request for informal written reconsideration was not made within 15 calendar days from the "sent" date of the e-mail notification from CMS' RDS Center that indicates the adverse initial determination. The request for informal written reconsideration was not timely made and therefore will not be reviewed by CMS' RDS Center.
"Pending": The request for informal written reconsideration has been received by CMS' RDS Center and has been placed in this status while another request by the Plan Sponsor is in "Appeal Under Review" status. A decision has not been made. If a Plan Sponsor wishes to submit additional documentary evidence for CMS' RDS Center to consider, they should submit such documentation immediately. Please include a documentary evidence cover sheet that specifies your application number. A Sample Supporting Documentary Evidence Cover Sheet (pdf, 20.5kb) has been provided for your convenience.
"Withdrawn": The Plan Sponsor has withdrawn the request for informal written reconsideration through the RDS Secure Web Site before CMS' RDS Center made a decision. No decision will be made by CMS' RDS Center on withdrawn requests for informal written reconsideration.
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