Appeal Instructions

Prescribers & Pharmacists

• General Appeal Instructions
  • You may submit the appeal requests and subsequent documentation through one of the following methods:
    • QIC Appeals Portal
    • Fax
    • Mail / Courier

• Only submit one reconsideration request and one case file per submission.
• Please submit all case file documentation for the appeal at the same time in a single submission.
• Please do not submit the same request for an appeal more than once. For example, if you submit through the QIC Appeals Portal, then do not fax the same submission. Submitting the same request more than once creates duplicate appeals and may delay proper processing of your appeal.
• For Prescription Drug Benefit Appeal Requests:
  • Please complete and submit the Request for Reconsideration of Medicare Prescription Drug Denial Form provided by your Part D Plan with the plan’s redetermination letter.
  • Clearly identify the enrollee’s first/last name and MBI number, Part D Plan and drug at issue.
  • If available, please attach and submit the plan’s Redetermination decision with your appeal request.
  • Clearly identify the prescriber’s first/last name, mailing address, and telephone and fax number. For formulary exception requests, include a detailed statement in support of the request along with supporting medical records.
• If you wish to submit more documentation after you have submitted an appeal request, please attach a cover sheet that states ‘Additional Documentation.’ Identify the enrollee’s first/last name and MBI number, Part D Plan, appeal type (Drug Benefit Appeal or LEP Appeal), and the additional information you are submitting (e.g. physician letter, medical records, Notice of Creditable Coverage).
• Our portal permits users to identify a brief nickname (characters) for the submission. Do not use Personal Health Information (PHI) or Personally Identifiable Information (PII) for your nickname since the email confirmation we send is not secure.

• QIC Appeals Portal Instructions
  • QIC Appeals Portal User Guide (PDF)
  • The QIC Appeals Portal permits users to identify a brief nickname (characters) for the submission. Do not use Personal Health Information (PHI) or Personally Identifiable Information (PII) for your nickname since the email confirmation we send is not secure.