42 C.F.R. § 423.584 Expediting certain redeterminations.
Title 42 - Public Health
(a) Who may request an expedited redetermination. An enrollee or an enrollee's prescribing physician may request that a Part D plan sponsor expedite a redetermination that involves the issues specified in §423.566(b). (This does not include requests for payment of drugs already furnished.) (b) How to make a request. (1) To ask for an expedited redetermination, an enrollee or a prescribing physician acting on behalf of an enrollee must submit an oral or written request directly to the Part D plan sponsor or, if applicable, to the entity responsible for making the redetermination, as directed by the Part D plan sponsor. (2) A prescribing physician may provide oral or written support for an enrollee's request for an expedited redetermination. (c) How the Part D plan sponsor must process requests. The Part D plan sponsor must establish and maintain the following procedures for processing requests for expedited redetermination: (1) Handling of requests. The Part D plan sponsor must establish an efficient and convenient means for individuals to submit oral or written requests, document all oral requests in writing, and maintain the documentation in the case file. (2) Prompt decision making. The Part D plan sponsor must promptly decide whether to expedite the redetermination or follow the timeframe for standard redetermination based on the following requirements: (i) For a request made by an enrollee, the Part D plan sponsor must provide an expedited redetermination if it determines that applying the standard timeframe for making a redetermination may seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. (ii) For a request made or supported by a prescribing physician, the Part D plan sponsor must provide an expedited redetermination if the physician indicates that applying the standard timeframe for conducting a redetermination may seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. (d) Actions following denial of a request. If a Part D plan sponsor denies a request for expedited redetermination, it must take the following actions: (1) Make the determination within the 7-day timeframe established in §423.590(a). The 7-day period begins the day the Part D plan sponsor receives the request for expedited redetermination. (2) Give the enrollee prompt oral notice of the denial that— (i) Explains that the Part D plan sponsor processes the enrollee's request using the 7-day timeframe for standard redetermination; (ii) Informs the enrollee of the right to file an expedited grievance if he or she disagrees with the decision by the Part D plan sponsor not to expedite; (iii) Informs the enrollee of the right to resubmit a request for an expedited redetermination with the prescribing physician's support; and (iv) Provides instructions about the expedited grievance process and its timeframes. (3) Subsequently deliver, within three calendar days, equivalent written notice. (e) Action following acceptance of a request. If a Part D plan sponsor grants a request for expedited redetermination, it must conduct the redetermination and give notice in accordance with §423.590(d).
Title 42: Public Health
PART 423—VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
Subpart M—Grievances, Coverage Determinations, and Appeals
§ 423.584 Expediting certain redeterminations.
