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Appeal Level 2 & 3: Medicare Advantage Plan

Sudhir Mathuria  Licensed  Professional Health Life 360 6776 Southwest Freeway, Suite # 178 Houston TX 77074 713-771-2900 www.MyMedicarePlanning.com

Sudhir Mathuria
Licensed Professional
Health Life 360
6776 Southwest Freeway, Suite # 178
Houston TX 77074

Appeals – Level 2: Independent Review Entity (IRE)
If your plan decides against your reconsideration, they must send you a notice that gives you the specific reason(s) for any full or partial denial.
You may send an Independent Review Entity (IRE) information about your case. They must get this information within 10 days after the date you get the notice telling you your case file has been sent to the IRE. The IRE’s address is on the notice.
How long it takes for the IRE to send you its decision in a written Reconsideration Determination depends on the type of request:
• Expedited (fast) request—72 hours
• Standard service request—30 days
• Payment request—60 days
You’ll get a fast decision if the IRE determines that your life or health may be at risk by waiting for a standard service decision

Appeals – Level 3: Request for Medicare Hearing
A hearing before an Administrative Law Judge (ALJ) allows you to present your appeal to a next level. The ALJ will review the facts of your appeal independently and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, or in some cases, in person. You can also ask the ALJ to make a decision without a hearing. The ALJ may also issue a decision without holding a hearing if evidence in the hearing record supports a decision that’s fully in your favor.
To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2017, the required minimum amount is $160. The ALJ will decide if your case meets the minimum dollar amount. You may be able to combine claims to meet the minimum dollar amount.
If you have Original Medicare, follow the directions on the “Medicare Reconsideration Notice” you got from the QIC in level 2 to request a hearing before an ALJ. You must send your request to the appropriate Office of Medicare Hearings and Appeals (OMHA) Central Operations. The address is listed in the QIC’s reconsideration notice.
If you have Original Medicare, a Medicare Advantage plan, other Medicare health plan, or a Medicare Prescription Drug Plan, you can request a hearing in one of these ways:
1. Fill out a “Request for Medicare Hearing by an Administrative Law Judge” form
2. Submit a written request to the OMHA office that will handle your ALJ hearing that includes:
• Your name, address, and Medicare number. If you’ve appointed a representative, include your representative’s name and address.
• The appeal number included on the QIC reconsideration notice, if any.
• The dates of service for the items or services you’re appealing. See your MSN or reconsideration notice for this information.
• An explanation of why you disagree with the reconsideration decision being appealed.
• Any information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it
3. If the ALJ doesn’t issue a timely decision, you may ask the ALJ to move your case to the next level of appeal.
4. If you disagree with the ALJ’s decision in level 3, you have 60 days after you get the decision to request a review by the Medicare Appeals Council (Appeals Council).
(-To Be Continued)

To choose right Medicare Advantage Plan, Medicare Supplement Plan or Medicare Prescription plan contact Sudhir Mathuria @ 713-771-2900.

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