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Reconsideration Procedures Manual

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Part D QIC Reconsideration Procedures Manual (PDF)

Reconsideration Procedures Manual Log
Version # Effective Date Description
1 February 2021 Creation
2 February 2021 Style changes to “C2C Contact Information” page
3 March 2021 Style changes to “C2C Contact Information” page
4 June 2021
  1. Updated Section 7.3.4 “Dismissal of a LEP Reconsideration Request” to clarify processing of unsigned requests
  2. Updated Plan Liaison name after staffing change
  3. Updated Medical Director name after staffing change
5 January 2022 Added Section 6.9.3 “Part D QIC review of plan dismissal appeal requests” to document processing of new appeal type
6 February 2023
  1. Updated Section 8.2.2 “Process for Part D Plan requesting a reopening” to clarify processing of Plan reopening requests
  2. Added Section 8.3.3 “Requesting Missing Information (RFI)” to document process for OMHA RFIs
  3. Updated section 8.3.5 “OMHA Decisions” to clarify effectuation process and added process for when the QIC did not (or has not yet received notice) of an OMHA Decision but the Plans have.
  4. Added Section 8.3.6 “OMHA Remands” to document processing of OMHA Remands
  5. Updated Section 8.4.2 “Referral to the Council for Own Motion Review” to clarify the process for referrals
  6. Added Section 8.4.3 “Medicare Appeals Council Decisions” to document Council decision effectuations
7 May 2023 Updated Plan Liaison name after staffing change
8 August 2023 Updated address to C2C’s new physical address
9 November 2023 Updated Program Director and edited grammar for 8.4.2 Referral to the Council for Own Motion Review
10 March 2024
  1. Updated Section 3.2.1 “Designation of a key plan contact, phone number, fax number and email” Providing clear instructions for completing the Plan Contact Form
  2. Updated Section 8.2.2 “Process for Part D plan requesting a reopening” to clarify Reopening Request requirements and instructions
  3. Updated address to C2C’s new physical address
  4. Corrected document version value citations within manual
11 January 2025
  1. Updated C2C Contact information page to remove identifying staff names
  2. Updated Sections 2.31, 4.4.1, 4.4.2, 5.1, and 6.9 to reflect change in appeal timeframe prescription drug appeals from 60 days to 65 days
  3. Updated Section 3.4 to clarify the additional five-day mail rule does not apply to prescription drug appeals
12 December 2025
  1. Updated 2.11 to add Indian Health Service, a Tribe or Tribal organization or an Urban Indian organization (I/T/U) and removed Medicare supplemental (Medigap)
  2. Updated 2.12 for verbiage to closely match 42 CFR 423.56(e)
  3. Updated 2.19 to include "Generally"
  4. Updated 2.21 for clarification that Low-Income Subsidy (LIS) eligible months do not count towards the late penalty
  5. Updated 2.32 to clarify "all impacted" Medicare Part D plans
  6. Updated Section 3.2.1 to remove Report Contact Information
  7. Updated Section 3.3.1 to clarify holidays
  8. Updated Section 3.3.2 to clarify directions on how to submit appeals
  9. Updated Section 4.4.3 to clarify how to submit large volume auto-forward drops
  10. Updated Section 4.4.4 to more closely match Section 50.8 of the current Centers for Medicare & Medicaid Services (CMS) manual
  11. Updated Section 7.1.2 J for clarification
  12. Updated Section 7.3.2 to reflect changes made to the QIC Favorable and Partially Favorable LEP decision letters
  13. Updated Section 7.4.1 to remove "The Part D plan must report a revised creditable coverage period determination indication 0 (zero) uncovered months to CMS effected with the LIS eligibility date," and added "Note: For LIS-eligible beneficiaries, MARx automatically resets any LEP. The Part D plan only needs to contact the MAPD Help Desk if MARx fails to reset the LEP"
  14. Updated 7.4.2 for clarification
  15. Updated 7.4.4 to remove the plan reporting of revised creditable coverage period and entered a note related to how MARx automatically resets LEP and creditable coverage periods when a new IEP begins
  16. Updated Section 8.1.1 to clarify effectuation requirements when an appeal is reopened for corrections