Frequently Asked Questions

Q1. What documentation must a Part D plan include when submitting a drug appeal case file to the Part D QIC?

Q2. Where should Part D plans send drug case files and related correspondence to the Part D QIC?

Q3. How long will it take for the Part D QIC to issue a decision?

Q4. How can a Part D plan ensure the Part D QIC has the correct plan contact information for requesting case files?

Q5. Why are Part D plans required to include the Evidence of Coverage (EOC) with each drug appeal case file submission?

Q6. How should a Part D plan notify the Part D QIC regarding multiple auto forwarded cases?

Q7. What documents should Part D plans send to the Part D QIC based on untimely or missed timeframe determinations?

Q8. What if the Part D plan has approved the drug(s) but missed its time frame for timely notification of the approval?

Q9. Why is it important to include the correct Part D plan contract number and plan ID number with each case file?

Q10. Why does the Part D QIC require a HICN for case processing rather than the Part D plan member identification number?

Q11. Where do Part D plans send completed Notices of Effectuation?

Q12. What documentation should a Part D plan include when submitting an LEP case file to the Part D QIC?

Q13. Where should Part D plans send LEP case files and related correspondence to the Part D QIC?

Q14. Is the Part D plan required to submit an LEP case file to the Part D QIC for an enrollee who is no longer a plan member?

Q15. How should a Part D plan respond to a Case File Request from the Part D QIC if it has no applicable documentation regarding an appeal?

Q16. Is the Part D plan required to submit a case file to the Part D QIC if the plan has rescinded the LEP?

Q17. Is the Part D plan required to submit a case file to the Part D QIC if the enrollee was not assessed an LEP?

Q18. How should a Part D plan proceed when submitting an LEP case file beyond the fourteen (14) day submission deadline?

Q19. When will the Part D plan receive notification of the LEP appeal decision?

Q20. How should a Part D plan proceed if it disagrees with the Part D QIC’s final decision?

Q21. When should the Part D Plan select YES to the new question in the Case File submission to the Part D QIC “Is this enrollee deemed ‘at- risk’”?

Q22. What should the Part D plan do if we receive a case file request from the Part D QIC for an appeal that an initial determination and redetermination was not issued?

Q23. The Part D plan received an overturned decision letter from the Part D QIC wherein the Prescriber Reviewer accepted an Orphan drug designation for the medically accepted indication, why?

Q24. What information was provided in the prescriber statement letter to the Part D QIC that explained why the Part D plan’s covered alternatives in the formulary would likely not be as effective as the requested drug?

Q25. What does the Part D plan do if they believe the Part D QIC’s reconsideration decision is erroneous and/or should be modified due to new and material information not previously available or known?

Q26. The Part D plan has determined that a case was sent to the Part D QIC in error as an auto-forward/out-of-compliance Part D appeal; however, they have since determined that this request was a duplicate of an appeal that was already upheld timely. How do we withdraw the appeal?

 


Q1. What documentation must a Part D plan include when submitting a drug appeal case file to the Part D QIC?

Answer:

 

The Reconsideration Case File Transmittal Form and Case Narrative Form must be included and be fully completed. The information requested on these forms has been carefully considered and approved by CMS as necessary for case processing. These forms are available on this website by clicking on the form names.

The Reconsideration Case File Transmittal form identifies the procedural and evidentiary exhibits that a Part D plan may be required to submit with a case file depending on the drug benefit in dispute. These exhibits are listed on page 3 of the Reconsideration Case File Transmittal Form. For more information regarding these exhibits, please refer to the Reconsideration Procedures Manual.

If the Part D plan requires further assistance with identifying the exhibits that should be presented with a case file, they should contact the Plan Liaison at the Part D QIC for assistance. Please click on "Contact Us" above for contact information.

 


Q2. Where should Part D plans send drug case files and related correspondence to the Part D QIC?

Answer:

 

MAXIMUS Federal Services has consolidated its operations and is processing all Drug Benefit and LEP appeals at the Pittsford, NY site. Part D plan sponsors are reminded that their appeals processes and forms must reflect the following Part D QIC case filing location:

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Avenue, Suite 703
Pittsford, NY 14534-1302
Fax number: (585) 425-5301
Customer Service: (585) 348-3400

 

Part D plan case files may also be submitted electronically via the QIC Appeals Portal: https://qicappeals.cms.gov

Some of the benefits of the MAXIMUS Federal QIC Appeals Portal are:
  • Secure login and submission (permits plans to securely transmit appeals case files);
  • Online appeal case file submission forms (eliminating paper forms);
  • Immediate confirmation of submission (including a confirmation number); and
  • Ability to upload and submit files electronically (eliminating mailing and shipping costs, faxing, and CDs).

Q3. How long will it take for the Part D QIC to issue a decision?

Answer:

Decisions for valid expedited appeals are generally faxed to the Part D plan within 72 hours. Decisions for standard appeals are generally faxed within 7 calendar days. Processing may be delayed if an appeal is brought by a representative and is lacking an appointment of representative form or other applicable representation documents. Likewise, if a prescriber statement is required to process the appeal and is either lacking or is inadequate, processing may be delayed while the Part D QIC attempts to obtain this information. We allow 14 days for a response for representation documentation and for prescriber information.

 


Q4. How can a Part D plan ensure the Part D QIC has the correct plan contact information for requesting case files?

Answer:

Part D plans are responsible for communicating all contact information, including changes to the Part D QIC. Part D plans must complete a Plan Contact Form. This information includes the Part D plan’s fax number, phone number, address and main point of contact for both Drug and LEP appeals, respectively, as well as a Reporting Contact. With the inclusion of new Part D plans each year, it is imperative that the Part D QIC receives the plan’s preferred contact information. This information is logged into a database and utilized for requesting case files and for general communication. If contact information has changed, fax or email an updated Plan Contact Form to the Plan Liaison ASAP.

 


Q5. Why are Part D plans required to include the Evidence of Coverage (EOC) with each drug appeal case file submission?

Answer:

CMS mandates that Part D plans provide the entire EOC and formulary for the reconsideration process, especially since these documents are required for further levels of appeal with the ALJs and the Medicare Appeals Council. Currently CMS strongly recommends that Part D plans provide the Part D QIC with the EOC and formulary information via CD. Part D plans are encouraged to review the pertinent evidentiary and procedural documentation on page 3 of the Reconsideration Case File Transmittal Form for the information the Part D QIC uses to efficiently render meaningful decisions for enrollees.


Q6. How should a Part D plan notify the Part D QIC regarding multiple auto forwarded cases?

Answer:

If the volume of auto forwarded cases exceeds 20 or more cases at one time, please notify the Plan Liaison directly at phone number 585-348-3358 or via email.


Q7. What documents should Part D plans send to the Part D QIC based on untimely or missed timeframe determinations?

Answer:

For appeals involving untimely or auto-forwarded case files, Part D plans must include the following information:

  1. Enrollee’s name;
  2. Enrollee’s Medicare Claim Number;
  3. Identification of the item for which Reconsideration is requested, e.g., the prescription drug, including dose and quantity;
  4. Name of the authorized representative, if applicable, and documentation of valid appointment;
  5. Name and contact information of the prescriber; and
  6. Name of the Part D plan that made the determination.

Although auto-forwards at the coverage determination level usually contain limited information, prescriber information is crucial at all levels including the initial coverage determination (level 0). Part D plans are reminded that the Part D QIC relies on complete and accurate prescriber information in order to efficiently render meaningful decisions for enrollees.


Q8. What if the Part D plan has approved the drug(s) but missed its time frame for timely notification of the approval?

Answer:

In this instance, the Part D plan must auto-forward the case file to the Part D QIC. Submit the approval notices along with the case file and indicate on the Case Narrative that coverage is being provided.

Please include the following details on the Case Narrative:

·         The drug(s) at issue, including brand/ generic name, dose and quantity being requested;

·         The actual dates of coverage which were approved.

It is also imperative that a screen shot or authorization page/approval notice be included with each case file as proof of coverage.

 


Q9. Why is it important to include the correct Part D plan contract number and plan ID number with each case file?

Answer:

The correct Part D plan contract number and plan ID number for the enrollee are critical to accurate processing of the Reconsideration decision. Many Reconsideration decisions issued by the Part D QIC consider language in the EOC and/or the formulary status of the drug at issue. The Part D plan contract number and plan ID allow the Part D QIC to confirm that the correct EOC and formulary are in the record. The Part D QIC requires the correct plan documentation in the case record to perform a meaningful substantive review of an appeal.


Q10. Why does the Part D QIC require a HICN for case processing rather than the Part D plan member identification number?

Answer:

The full Medicare Health Insurance Claim Number (HICN) must be provided on each submission from Part D plans in the correct section on the Case File Transmittal Form. The HICN is the unique identifier issued from Medicare. The Part D QIC cannot use internal member identification numbers, since these numbers are plan-specific and do not allow for tracking of enrollees in Medicare databases.


Q11. Where do Part D plans send completed Notices of Effectuation?

Answer:

Part D plans can mail the Notices to:

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Avenue, Suite 703
Pittsford, NY 14534-1302
Or fax to the Effectuation Only fax number (585) 869-3399


Q12. What documentation should a Part D plan include when submitting an LEP case file to the Part D QIC?

Answer:

The LEP Case File Transmittal Form and Case Narrative must be fully completed and submitted to the Part D QIC by mail or fax within fourteen (14) calendar days after receiving the case file request. These two (2) forms should be submitted with every case file. Note that the information requested on these forms has been carefully considered and approved by CMS for LEP appeal processing.

The LEP Case File Transmittal Form identifies the procedural and evidentiary exhibits that a Part D plan may be required to submit with a case file. For more information regarding these exhibits, please refer to the Reconsideration Procedures Manual.

If the Part D plan requires further assistance with identifying the exhibits that should be submitted with a case file, they should contact the Plan Liaison at the Part D QIC for assistance. Please click on "Contact Us" above for contact information.


Q13. Where should Part D plans send LEP case files and related correspondence to the Part D QIC?

Answer:

MAXIMUS Federal Services has consolidated its operations and is processing all Drug Benefit and LEP appeals at the Pittsford, NY site. Appeals will no longer be processed at the King of Prussia, PA facility. Part D plan sponsors are reminded that their appeals processes and forms must reflect the following Part D QIC case filing location:

MAXIMUS Federal Services
Medicare Part D QIC
3750 Monroe Avenue, Suite 704
Pittsford, NY 14534-1302
Fax number: (585) 869-330 3320
Customer Service: (585) 348-3400


Q14. Is the Part D plan required to submit an LEP case file to the Part D QIC for an enrollee who is no longer a plan member?

Answer:

Yes. If the Part D QIC requests a case file for an enrollee who is no longer a plan member, that Part D plan is required to submit a case file to the Part D QIC within fourteen (14) calendar days by mail or fax after receiving the Case File Request Form. The Part D QIC will generally only request a case file from the Part D plan that originally assessed the LEP, so even if the enrollee is no longer a plan member, the Part D plan is required to provide a complete case file.


Q15. How should a Part D plan respond to a Case File Request from the Part D QIC if it has no applicable documentation regarding an appeal?

Answer:

If the Part D plan has no documentation regarding the LEP, the Part D plan shall return the Case File Transmittal Form by mail or fax to the Part D QIC within fourteen (14) calendar days after receiving the Case File Request Form, acknowledge that the requested documentation is unavailable and explain the reason(s) why.

 


Q16. Is the Part D plan required to submit a case file to the Part D QIC if the plan has rescinded the LEP?

Answer:

The Part D plan is required to return the Case File Request Form to the Part D QIC by mail or fax within fourteen (14) calendar days after receiving the Part D QIC’s Case File Request Form, indicating that the LEP has been rescinded. The Part D plan shall also indicate the following on the Case File Request Form:

  1. Date the LEP was rescinded; and,
  2. Date enrollee notified that the Late Enrollment Penalty was rescinded.

Note that the Part D plan is not required to forward a completed case file containing the procedural and evidentiary documentation to the Part D QIC when an LEP has been rescinded.

 


Q17. Is the Part D plan required to submit a case file to the Part D QIC if the enrollee was not assessed an LEP?

Answer:

The Part D plan is required to return the Case File Request Form by mail or fax within fourteen (14) calendar days after receiving the Case File Request Form, indicating that the that the enrollee was not assessed an LEP. However, the Part D plan is not required to forward a completed case file containing procedural and evidentiary documentation when an LEP has been rescinded.

 


Q18. How should a Part D plan proceed when submitting an LEP case file beyond the fourteen (14) day submission deadline?

Answer:

The Part D plan should make its best effort to submit a completed LEP case file by mail or fax within fourteen (14) calendar days after receiving the Case File Request Form. In the event that the Part D plan cannot meet this timeframe, the Part D QIC will accept case file submissions that are beyond the submission deadline. Late case file submissions will also be recorded in the Medicare Appeals System (MAS) and reported to CMS. However, Part D plans should be aware that that the Part D QIC may have already reached a decision when the Part D plan submits a late case file.


Q19. When will the Part D plan receive notification of the LEP appeal decision?

Answer:

The Part D QIC strives to notify the appellant and the Part D plan of the final decision as soon as possible, usually within 90 days of receipt of the appeal request. However, in certain circumstances the appeal may be processed within a shorter time frame. Generally, the Part D plan will receive a copy of the final decision letter by fax. Upon receipt of the final decision letter, the Part D plan has ninety (90) days to effectuate a Favorable or Partially Favorable decision.


Q20. How should a Part D plan proceed if it disagrees with the LEP final decision?

Answer:

The LEP appeal decision issued by the Part D QIC is final and not subject to further appeal. However, if the Part D plan disagrees with the final decision, it may request reopening of the LEP reconsideration decision. The Part D plan should submit a detailed written request for reopening within 180 days from the date of the LEP Reconsideration decision. The Part D QIC will only reopen an LEP appeal for the following reasons:

  1. To correct an error;
  2. If fraud is suspected; and,
  3. If there is new information that might change the decision and this information was not previously available.

The Part D plan is required to comply with the LEP reconsideration decision until an LEP reopening decision is issued by the Part D QIC.


Q21. When should the Part D Plan select YES to the new question in the Case File submission to the Part D QIC “Is this enrollee deemed ‘at- risk’”?

Answer:

This should only be selected when the appeal is for an at-risk determination as defined by 42 C.F.R. § 423.100. Please see the link below for further clarification.

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/2019-Part-D-Drug-Management-Program-Policy-Guidance-Memo-November-20-2018-.pdf


Q22. What should the Part D plan do if we receive a case file request from the Part D QIC for an appeal that an initial determination and redetermination was not issued?

Answer:

The Part D QIC needs to track and report these cases. In order to assist the Part D QIC in that endeavor, please submit the case file and indicate there was no CD/RD. When selecting the representative option Part D plans should select NO as to the representative being validated if you do not have documentation indicating otherwise.


Q23. The Part D plan received an overturned decision letter from the Part D QIC wherein the Prescriber Reviewer accepted an Orphan drug designation for the medically accepted indication, why?

Answer:

Under Medicare Law, a positive citation is required within a Medicare approved compendia. The granting of orphan drug status by the Food and Drug Administration and the presence of the citation within DrugDex constitutes a positive citation. The Part D QIC is the Independent Review Entity and as such cannot provide interpretative guidance to plans.


Q24. What information was provided in the prescriber statement letter to the Part D QIC that explained why the Part D plan’s covered alternatives in the formulary would likely not be as effective as the requested drug?

Answer:

The Part D QIC is unable to provide the specific information contained within the prescriber statement. The Part D QIC received a sufficient prescriber statement letter that fulfilled the requirements of “Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance,” section 40.5.3--Supporting Statements for Exceptions Requests. As an Independent Review Entity, the Part D QIC is not at liberty to divulge the specific information contained within the prescriber statement. If the Part D plan feels that the decision needs to be reopened, they can specifically request a reopening.


Q25. What does the Part D plan do if they believe the Part D QIC’s reconsideration decision is erroneous and/or should be modified due to new and material information not previously available or known?

Answer:

When a Part D plan believes that the Part D QIC reconsideration decision is erroneous and/or should be modified due to new and material information not previously available or known, the Part D plan may submit a written or verbal statement to the Part D QIC that sets forth this information. If the Part D plan alleges error as a basis for reopening, the Part D plan should clearly describe its rationale for concluding that the reconsideration decision is erroneous on the face of the evidence. If the Part D plan alleges new and material information as a basis for reopening, the Part D plan should clearly identify the new information it has received, explain why the information was not previously available, and explain how the new information may modify the Reconsideration decision. The Part D QIC will evaluate the written or verbal statement submitted by the Part D plan and determine if there is good cause for reopening review. If the Part D QIC does not find good cause for reopening, the Part D QIC will notify the Part D plan about its decision not to reopen. If the Part D QIC does find good cause for reopening, the Part D QIC will reopen on its own motion and process the request.

A Part D plan request for reopening (see Section 8.2 of this manual), whether granted by the Part D QIC or not, does not stay the date of the Part D plan’s compliance obligation.

When submitting the reopening request, please clearly state on the transmittal form to the Part D QIC that this is a request for reopening.


Q26. The Part D plan has determined that a case was sent to the Part D QIC in error as an auto-forward/out-of-compliance Part D appeal; however, they have since determined that this request was a duplicate of an appeal that was already upheld timely. How do we withdraw the appeal?

Answer:

In order to move forward with withdrawing/reclassifying this case from “uphold” to “dismiss”, please submit evidence that the claim was processed timely such as a copy of the verbal or written notification letter to the beneficiary or phone logs to the Part D QIC.

Part D Footer