If your plan decides against your reconsideration, they must send you a notice that gives you the specific reason(s) for any full or partial denial.
You may send an Independent Review Entity (IRE) information about your case. They must get this information within 10 days after the date you get the notice telling you your case file has been sent to the IRE. The IRE’s address is on the notice.
You may want your doctor or other prescriber (for prescription drug appeals) to request this appeal on your behalf. If so, you’ll need to submit an “Appointment of Representative” form [PDF, 47.7KB].
How long it takes for the IRE to send you its decision in a written Reconsideration Determination depends on the type of request:
- Expedited (fast) request—72 hours
- Standard service request—30 days
- Payment request—60 days
You'll get a fast decision if the IRE determines that your life or health may be at risk by waiting for a standard service decision.
Some IREs call themselves “Part C QICs.”
If you disagree with the IRE's decision in level 2, you have 60 days from the date of the IRE's decision to request an Administrative Law Judge (ALJ) hearing.