CMS Ruling Addresses Own Motion Review of Medicare Part D Cases by Medicare Appeals Council

On March 23, 2007, the Centers for Medicare & Medicaid Services (CMS) published a Notice in the Federal Register announcing a CMS Ruling that establishes a process for own motion review of Medicare Part D prescription drug cases by the Medicare Appeals Council (MAC).

According to the Notice, the CMS Ruling permits CMS or a Medicare Part D independent review entity (IRE) to refer a Medicare Part D case to the MAC, and for the MAC to accept review, if an administrative law judge's (ALJ) decision or dismissal:

• contains an error of law material to the outcome of the case; or
• presents a broad policy or procedural issue that may affect the general public interest.

However, the CMS Ruling does not allow a Medicare Part D plan sponsor to refer a Medicare Part D case to the MAC for own motion review.  Nevertheless, the Notice states that Medicare Part D plan sponsors will "continue to have the opportunity to communicate with the Part D IRE about cases that may warrant such referral."

Further, the CMS Ruling applies many of the provisions in 42 C.F.R. 405.1110 to Medicare Part D cases.  For instance, the CMS Ruling indicates that a 60-day time frame for filing a written referral, and for providing notice to other interested parties, is appropriate for Part D cases.  In the Notice, CMS also cites other existing appeal provisions that would be applicable to the Part D cases.

According to the Notice, the CMS Ruling became effective on March 15, 2007, and after being signed by Acting CMS Administrator, Leslie V. Norwalk.