Reconsideration by Part C Independent Review Entity (IRE)

If a Medicare Advantage (Part C) health plan makes an adverse reconsideration decision (upholds its initial adverse organization determination), in whole or in part, the plan must automatically submit the case file and its decision for review by the Part C Independent Review Entity (IRE). If the plan dismisses a plan reconsideration request, the enrollee, the enrollee’s representative or non-contract provider has the right to file a request for review of the plan dismissal with the IRE.

For more information about appeals and dismissal review requests with the Part C IRE, see Section 60 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the “Downloads” section below.

How to Request an IRE Review of a Plan Dismissal

An enrollee, an enrollee's representative, or a non-contract provider may request a reconsideration of a plan dismissal.

The request must be filed with the IRE within 60 calendar days from the date of the plan dismissal decision notice.
The request must be made in writing, which includes by fax.
The request must be sent to the IRE, MAXIMUS, at:

Maximus
Medicare Managed Care & PACE Reconsideration Project
3750 Monroe Avenue
Suite 702
Pittsford, NY 14534-1302
Fax: 585-425-5292

Currently, MAXIMUS Federal Services is the Part C IRE. For additional information about MAXIMUS' reconsideration process, click on the MAXIMUS Federal Services link in the “Related Links” section below.

How the IRE Processes Reconsideration Requests

Once the case file or appeal is received by the IRE, the IRE must make its decision and provide written notice of its decision as quickly as the enrollee's health requires, but no later than the following timeframes:

Expedited requests: 72 hours
Standard Pre-service requests: 30 calendar days
Standard Part B drug requests: 7 calendar days
Payments requests: 60 calendar days

An extension of up to 14 calendar days is available if:

requested by the enrollee; or
actions are required by the QIC to address deficiencies in the reconsideration case file, with appropriate notification to the enrollee in accordance with regulations.

The QIC shall document the case file with the justification and rationale for the extension

Extensions are not permitted for Part B drug requests.

If the decision is unfavorable or partially favorable, the decision notice will contain the information needed to file a request for a hearing with an Administrative Law Judge within the Office of Medicare Hearings and Appeals (OMHA). Parties to the hearing may waive their right to the oral hearing and request that a decision be made based on the record. Use the left navigation menu on this page to link to other pages that contain detailed information about hearings with an ALJ and obtaining an on the record review by OMHA, or any other level of appeal.

Fact Sheets: Part C Reconsideration Appeals Data

These reports summarize and highlight key Part C IRE reconsideration data from January 1, 2017 to the most recently available date.

To view the Fact Sheets, click on the link in the "Downloads" section below.