CurrentMedicarePolicy N/A

Coverage Determination and Appeals Process

Governance of coverage determination requests, tiering/formulary exceptions, and appeals timeframes for Medicare Part D enrollees and their representatives; applies to Medicare Advantage and Prescription Drug Plans.

Policy Summary

PayerMedicare

PolicyCoverage Determination and Appeals Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFile a coverage determination to request tiering or formulary exceptions; request may be submitted by the enrollee, their appointed representative, or the prescribing clinician.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65-dayLevel 1 appeals deadline (from notice)

60-dayALJ hearing deadline (from receipt)

2026AIC reference year

Coverage Determination & Appeals Procedures

Procedural rules and timelines for coverage determinations, exceptions, and appeals.

Coverage determination requests include requests for tiering exceptions or formulary exceptions; a request may be filed by the enrollee, the enrollee's appointed representative, or the enrollee's physician/other prescriber.

Adjudication timeframes generally begin when the plan sponsor receives the request.

If the request involves an exception, the adjudication timeframe begins when the plan sponsor receives the physician's supporting statement.

If on redetermination the plan sponsor upholds an at-risk determination under 42 CFR § 423.153(f), the plan sponsor must auto-forward the case to the Part D IRE.

ALL of the following

Policy Summary

PayerMedicare

PolicyCoverage Determination and Appeals Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFile a coverage determination to request tiering or formulary exceptions; request may be submitted by the enrollee, their appointed representative, or the prescribing clinician.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Filing and Requesting Coverage Determinations

Prior Authorization

Filing a Coverage Determination (who may file and timing)

A request for a coverage determination includes requests for tiering exceptions or formulary exceptions and may be filed by the enrollee, the enrollee's appointed representative, or the enrollee's physician/other prescriber. Adjudication timeframes generally begin when the plan sponsor receives the request; for exception requests, the timeframe begins when the plan sponsor receives the physician's supporting statement.

Includes tiering exceptions and formulary exceptions.
May be filed by the enrollee, the enrollee's appointed representative, or the enrollee's physician/other prescriber.
Adjudication timeframes begin on receipt by the plan sponsor; for exception requests, begin on receipt of the physician's supporting statement.

Key Definitions

AIC — Amount in Controversy definition

TermAmount in Controversy (AIC)

DefinitionThe monetary threshold used to determine jurisdiction for ALJ hearings and Federal District Court in Part D appeals processes

Adjustment noteAIC requirement for an ALJ hearing and Federal District Court is adjusted annually per the medical care component of the Consumer Price Index

ALJ — Administrative Law Judge definition

TermALJ (Administrative Law Judge)

RoleHears Part D appeals when the Amount in Controversy meets the applicable threshold; hearing deadlines run 60 days from date of receipt of the notice

ContextPart of the Medicare appeals process following level 1 and redetermination steps

IRE — Independent Review Entity definition

TermIRE (Independent Review Entity)

RoleReceives cases auto-forwarded by plan sponsors if, on redetermination, an at-risk determination under 42 CFR § 423.153(f) is upheld

ContextIndependent reviewer in Part D escalation process after plan sponsor redetermination

MA-PD — Medicare Advantage Prescription Drug plan definition

TermMA-PD (Medicare Advantage Prescription Drug plan)

DefinitionA Medicare Advantage plan that offers Part D prescription drug benefits

ScopeSubject to Part D coverage determination and appeals procedures described in this policy

PDP — Prescription Drug Plan definition

TermPDP (Prescription Drug Plan)

DefinitionA standalone Prescription Drug Plan providing Part D benefits

ScopeSubject to Part D coverage determination and appeals procedures described in this policy

OpenPayer

Coverage Determination and Appeals Process

Coverage Determination & Appeals Procedures

Amount-in-Controversy (AIC) Thresholds

Filing and Requesting Coverage Determinations

Key Definitions