Appeal an Initial Determination

User Roles:

AM

AR

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Program Components:

Annual Plan Application

Reconciliation

Overview

This section provides an overview of appealing an initial determination:

Introduction to Appeals

RDS Plan Sponsors have the right to appeal various types of RDS Program determinations in accordance with Federal regulations at 42 C.F.R. §423.890. An appeal can take the form of either a reconsideration or a reopening.

Appealable Initial Determinations

An initial determination is a decision made by CMS' RDS Center in response to information that the Plan Sponsor submitted. If a Plan Sponsor disagrees with the initial determination made by CMS' RDS Center, it can request a reconsideration or a reopening. The following are the two types of initial determinations for which a Plan Sponsor may request a reconsideration or a reopening.

Did not meet the Application Deadline:

For detailed information about the Application Deadline, including what is required to be submitted by the Application Deadline, refer to Important Application Deadline Information.

Reconciliation Final Payment:

The Plan Sponsor does not agree with the Reconciliation or final payment determination.

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Reconsideration versus Reopening

An appeal is classified as either a reconsideration or a reopening based on the timeframe in which the appeal is submitted:

Reconsideration Application Denial: This appeal type exists when the Plan Sponsor failed to meet the Application Deadline for a specific plan year. The request for reconsideration must be submitted within 15 calendar days from the "sent" date of the email notice from CMS' RDS Center that provides the initial determination.

Reopening Application Denial: This appeal type exists when a Plan Sponsor failed to meet the Application Deadline for a specific plan year.  The request for reopening must be submitted within 4 calendar years from the "sent" date of the email notice from CMS' RDS Center that provides the initial determination.

Reconsideration Reconciliation Final Payment: This appeal type exists when the Plan Sponsor has completed Reconciliation for a specific plan year and has discovered issues impacting subsidy dollars or has missed the Reconciliation Deadline. The request for reconsideration must be submitted within 15 calendar days from the "sent" date of the email notice from CMS' RDS Center that provides the initial determination.

Reopening Reconciliation Final Payment: This appeal type exists when the Plan Sponsor has either completed Reconciliation for a specific plan year and has discovered issues impacting subsidy dollars, or does not agree with an adverse Reconciliation final payment determination resulting from a missed Reconciliation Deadline. The request for reopening must be submitted within 4 calendar years from the "sent" date of the email notice from CMS' RDS Center that provides the initial determination.

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Three Levels of Reconsideration-Related Appeals

  • First level: Reconsideration
  • Second level: Informal Hearing
  • Third level: Administrator Review

The second and third levels of reconsideration-related appeals are not requested using the RDS Secure Website. Plan Sponsors receive instructions regarding how to request additional level of appeals once a first level appeal decision is made by CMS' RDS Center.

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Appeal User Roles

The Account Manager, Authorized Representative, and Designee with Submit Appeal privilege:

  • May request a reconsideration through the RDS Secure Website.
  • May withdraw or check the status of an appeal through the RDS Secure Website.
  • Will receive email notification regarding activity, decisions, and any next steps required.

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Appeal Statuses

The following table displays information about appeal statuses:

Appeal Statuses, Descriptions, and Actions
Status Description Action
Reconsideration Requested CMS' RDS Center has received a Plan Sponsor's request for reconsideration. If a Plan Sponsor wishes to submit additional documentary evidence for CMS' RDS Center to consider, they should submit such documentation immediately.
Reopening Requested CMS' RDS Center has received a Plan Sponsor's request for reopening. If a Plan Sponsor wishes to submit additional documentary evidence for CMS' RDS Center to consider, they should submit such documentation immediately.
Appeal Under Review CMS' RDS Center is currently reviewing the Plan Sponsor's request for reconsideration or reopening. If the Plan Sponsor wishes to submit additional documentary evidence for consideration, they should contact CMS' RDS Center immediately to ensure that this additional documentary evidence is received and reviewed before the reconsideration or reopening decision is made.
Approved CMS' RDS Center has reviewed the Plan Sponsor's request for reconsideration or reopening and reversed the adverse initial determination.  If further action is required on behalf of the Plan Sponsor, the Plan Sponsor will be notified by CMS' RDS Center.
Denied CMS' RDS Center has reviewed the Plan Sponsor's request for reconsideration or reopening and upheld the initial determination.

A Plan Sponsor dissatisfied with CMS' RDS Center reconsideration decision has the right to request an Informal Hearing.

Federal regulations at 42 CFR §423.890(d)(6) specify that a decision by CMS' RDS Center to deny a Plan Sponsor's request to reopen an initial or reconsidered determination is final and binding and cannot be appealed.

Invalid

The request for reconsideration was not submitted within 15 calendar days from the "sent" date of the email notice from CMS' RDS Center that indicates the initial determination.

The request for reopening was not submitted within 4 calendar years from the "sent" date of the email notice from CMS' RDS Center that indicates the initial determination.

The appeal request was submitted with an incorrect determination, or the application has no initial determination.

The request for reconsideration or reopening was not timely submitted, and, therefore, will not be reviewed by CMS' RDS Center.

The request for reconsideration or reopening was submitted before any determination had been made by CMS' RDS Center.

The request for reconsideration or reopening was submitted incorrectly because it identified an incorrect type of adverse determination as the subject of the request.

Pending The request for reconsideration or reopening has been received by CMS' RDS Center and has been placed in this status while another request by the Plan Sponsor is in "Appeal Under Review" status. A decision has not been made. If a Plan Sponsor wishes to submit additional documentary evidence for CMS' RDS Center to consider, they should submit such documentation immediately. Please include a Documentary Evidence cover sheet that specifies your Application ID.
Withdrawn

The Plan Sponsor has withdrawn the request for reconsideration through the RDS Secure Website before CMS' RDS Center made a decision.

The Plan Sponsor has withdrawn the request for reopening before CMS' RDS Center made a decision.

Reconsiderations or reopenings that a Plan Sponsor has withdrawn will not be reviewed by CMS' RDS Center.

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Preparing to Request a Reconsideration or Reopening

A reconsideration or a reopening may be requested through the RDS Secure Website when the Plan Sponsor disagrees with the initial determination made by CMS' RDS Center.

A reconsideration must be requested within 15 calendar days from the "sent" date of the email notice from CMS' RDS Center that provides the initial determination. All timely submitted reconsideration requests are reviewed by CMS' RDS Center.

A reopening must be requested within 4 calendar years from the “sent” date of the email notice from CMS' RDS Center that provides the initial determination.

Consider the following when submitting a request for a reconsideration or reopening:

  • A reconsideration or reopening request must be made for each initial determination you wish to appeal.
  • The request for a reconsideration or reopening must specify the findings or issues with which the Plan Sponsor disagrees and the reasons for the disagreements.
  • The request for a reconsideration or reopening may include additional documentary evidence the Plan Sponsor wishes CMS' RDS Center to consider. For more information about submitting additional documentary evidence, refer to Include Additional Documentary Evidence.

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Information to Include in Reopening Requests

Requests for reopening must comply with Federal regulations at 42 C.F.R. §423.890(d). The type of information to include in a reopening request varies depending on the type of initial determination:

Application Denial

The reopening request must include:

  • The Plan Sponsor's Name, Plan Sponsor ID, Application ID, and contact information.
  • A description of the specific facts and circumstances as to why the Plan Sponsor missed the Application Deadline.

If the request for reopening is submitted after one year, but within four years, of the determination at issue, an explanation of why good cause exists to reopen the determination. (For information on what constitutes good cause, see Federal regulations at 42 C.F.R. §423.890(d)(4).)

Reconciliation Final Payment Determination: Plan Sponsor Missed the Reconciliation Deadline

The reopening request must include:

  • The Plan Sponsor's Name, Plan Sponsor ID, Application ID, and contact information.
  • The gross costs, Cost Threshold Reductions, Cost Limit Reductions, and price concession amount that the Plan Sponsor wishes the subsidy to be based upon. (For this purpose, this data can either be broken down by Benefit Option by month, or can be submitted in the aggregate for the entire application.) These amounts should be based upon what the Plan Sponsor believes to be its accurate retiree list.
  • A description of the specific facts and circumstances as to why it missed the Reconciliation Deadline.
  • The number of retirees the Plan Sponsor wishes to include in its Covered Retiree List.

If the request for reopening is submitted after one year, but within four years, of the determination at issue, an explanation of why good cause exists to reopen the determination. (For information on what constitutes good cause, see Federal regulations at 42 C.F.R. §423.890(d)(4).)

Reconciliation Final Payment Determination: Plan Sponsor Correcting Inaccurate or Incomplete Data

The reopening request must include:

  • The Plan Sponsor's Name, Plan Sponsor ID, Application ID, and contact information.
  • Indication that the Plan Sponsor wishes to correct inaccurate or incomplete data, and is requesting a reopening.
  • A request that the Plan Sponsor be given the opportunity to formally submit the updated data, by Benefit Option, by month, by resubmitting its Reconciliation payment request or its final payment request using the RDS Secure Website. The Plan Sponsor should also disclose the amount of subsidy it received for the application.
  • The gross costs, Cost Threshold Reductions, Cost Limit Reductions, and price concession amount that the Plan Sponsor now wishes the subsidy to be based upon. (For this purpose, this data can either be broken down by Benefit Option by month, or can be submitted in the aggregate for the entire application.) These amounts should be based upon what the Plan Sponsor now believes to be its accurate retiree list.
  • A description of the specific facts and circumstances, including the specific reason(s) why the data submitted with the Reconciliation or Final Payment Request was inaccurate or incomplete, and whether or not the Plan Sponsor believes the Covered Retiree List it agreed to before submitting its Reconciliation or final payment request was accurate.
  • If the Plan Sponsor believes the Covered Retiree List agreed to before submitting Reconciliation or final payment request was inaccurate they must include the specific reason(s) why.
  • In any case, the Plan Sponsor must specify the number of retirees the Plan Sponsor now believes will be included in the new Covered Retiree List.

Note: If the Plan Sponsor wishes to notify CMS of a post-Reconciliation discrepancy and does NOT wish to request a reopening, refer to the Common Question "How would an RDS Plan Sponsor disclose to CMS the correct, post-Reconciliation or post-final payment data, and the difference in subsidy caused by the corrected data, other than by requesting a reopening?"

If the request for reopening is submitted after one year, but within four years, of the determination at issue, an explanation of why good cause exists to reopen the determination. (For information on what constitutes good cause, see Federal regulations at 42 C.F.R. §423.890(d)(4).)

See "How is the Retiree Drug Subsidy calculated for a given application?" for instructions on how the subsidy for an application is calculated.

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Include Supporting Documentary Evidence

If you wish to submit supporting documentary evidence for CMS' RDS Center to consider while reviewing the reconsideration or reopening request:

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Step-by-Step Instructions

This section provides step-by-step instructions for managing appeals:

Appeal an Application Denial

Refer to Preparing to Request a Reconsideration or Reopening and Information to Include in Reopening Requests for details to consider when submitting an appeal.

To access the RDS Secure Website, and navigate to the Application List page, refer to instructions to access the RDS Secure Website.

On the Application List page:

  1. Select Manage Appeals in the Account Settings Box.

     Select [Manage Appeals]

On the Manage Appeals page:

An * indicates a required field.

  1. *Select an Application ID from the dropdown and select Create Appeal.

     Select [Create Appeal]

On the Create Appeal page:

An * indicates a required field.

  1. *Select a Type of Appeal (Reopening or Reconsideration) from the dropdown.
  2. *Enter a Reason for Appeal.
  3. Select Continue to proceed with the appeal process, or select Cancel to return to the Manage Appeals page.

     Select [Continue]

On the Create an Appeal Verification page:

  1. Select Confirm to submit the appeal, or select Cancel to return to the Create Appeal page.

     Select [Confirm]

On the Create an Appeal Confirmation page:

  1. Select Continue to proceed to the Manage Appeals page.

     Select [Continue]

Note: A Plan Sponsor may also submit additional documentary evidence for CMS' RDS Center to consider while reviewing the appeal. For instructions, refer to Submit Supporting Documentation.

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Appeal a Reconciliation Final Payment Determination

Refer to Preparing to Request a Reconsideration or Reopening and Information to Include in Reopening Requests for details to consider when submitting an appeal.

To access the RDS Secure Website, and navigate to the Application List page, refer to instructions to access the RDS Secure Website.

On the Application List page:

  1. Select Manage Appeals in the Account Settings Box.

     Select [Manage Appeals]

On the Manage Appeals page:

An * indicates a required field.

  1. *Select an Application ID from the dropdown and select Create Appeal.

     Select [Create Appeal]

On the Create Appeal page:

An * indicates a required field.

  1. *Select a Type of Appeal (Reopening or Reconsideration) from the dropdown.
  2. *Enter a Reason for Appeal.
  3. Select Continue to proceed with the appeal process, or select Cancel to return to the Manage Appeals page.

     Select [Continue]

On the Covered Retiree List (CRL) and Application Level Costs page:

An * indicates a required field.

  1. *Select "Yes" or "No" for "Is the Reconciliation Covered Retiree List Correct?"

Note: If "No" is selected for "Is the Reconciliation Covered Retiree List Correct?," you are required to enter a New Estimated Retiree Count and Reason for Retiree Change.

  1. Verify or update the Application Level Costs for the application.
  2. Select Continue to proceed with the appeal submission process, or select Cancel to return to the Create Appeal page.

     Select [Continue]

  3. The Create Appeal Verification page displays. Select Confirm to submit the appeal.

     Select [Continue]

  4. The Create an Appeal Confirmation page displays. Select Continue to proceed to the Manage Appeals page.

     Select [Continue]

Note: A Plan Sponsor may also submit additional documentary evidence for CMS' RDS Center to consider while reviewing the appeal. For instructions, refer to Submit Supporting Documentation.

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View an Appeal

To access the RDS Secure Website, and navigate to the Application List page, refer to instructions to access the RDS Secure Website.

On the Application List page:

  1. Select Manage Appeals in the Account Settings Box.

     Select [Manage Appeals]

On the Manage Appeals page:

  1. Select the Appeal Tracking Number you wish to view.

     Select [Appeal Number]

On the View Appeal page:

  1. Review the details of the appeal. You may also begin the processes to either withdraw an appeal or submit supporting documentation from this page.
  2. Select Continue to return to the Manage Appeals page.

     Select [Continue]

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Submit Supporting Documentation

For details regarding what information to include in supporting documentation, refer to Include Supporting Documentary Evidence.

To access the RDS Secure Website, and navigate to the Application List page, refer to instructions to access the RDS Secure Website.

On the Application List page:

  1. Select Manage Appeals in the Account Settings Box.

     Select [Manage Appeals]

On the Manage Appeals page:

  1. Select the Appeal Tracking Number for which you wish to upload supporting documentation.

     Select [Appeal Tracking Number]

On the View Appeal page:

An * indicates a required field.

  1. *Provide the full path name of the file you would like to upload, or select Browse to find the file on your computer. After you locate the file, double click on the File Name to select it. (This process is similar to attaching a document to an email message.)
  2. Select Upload to begin the upload.
  3. Note: If all necessary supporting documents have been submitted for the appeal, select the checkbox indicating that the supporting documentation is complete.

     Select [Upload]

On the View Appeals page:

  1. The supporting documentation timestamp and file name display. Select Continue to return to the Manage Appeals page.

     Select [Continue]

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Withdraw an Appeal

To access the RDS Secure Website, and navigate to the Application List page, refer to instructions to access the RDS Secure Website.

On the Application List page:

  1. Select Manage Appeals in the Account Settings Box.

     Select [Manage Appeals]

On the Manage Appeals page:

  1. Select the Appeal Tracking Number you wish to withdraw.

     Select [Appeal Number]

On the View Appeal page:

  1. Select Withdraw Appeal.

     Select [Withdrawl Appeal]

On the Appeal Withdrawal Verification page:

  1. Select Confirm to withdraw the appeal, or select Cancel to return to the Manage Appeals page.

     Select [Confirm]

On the Appeal Withdrawal Confirmation page:

  1. Select Continue to proceed to the Manage Appeals page.

     Select [continue]

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