§ 423.582 Request for a standard redetermination. ( a ) *Method and place for filing a request.* An enrollee or an enrollee's prescribing physician or other prescriber (acting on behalf of the enrollee) must ask for a redetermination by making a written request with the Part D plan sponsor that made the coverage determination or the at-risk determination under a drug management program in accordance with § 423.153(f). The Part D plan sponsor may adopt a policy for accepting oral requests.
( b ) *Timeframe for filing a request.* Except as provided in paragraph (c) of this section, a request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice or the at-risk determination under a drug management program in accordance with § 423.153(f). ( 1 ) The date of receipt of the coverage determination or at-risk determination is presumed to be 5 calendar days after the date of the written coverage determination or at-risk determination, unless there is evidence to the contrary.
( 2 ) For purposes of meeting the 60-calendar day filing deadline, the request is considered as filed on the date it is received by the Part D plan sponsor or delegated entity specified in the Part D plan sponsor's written coverage determination or at-risk determination.
( c ) *Extending the time for filing a request* — ( 1 ) *General rule.* If an enrollee or prescribing physician or other prescriber acting on behalf of an enrollee shows good cause, the Part D plan sponsor may extend the timeframe for filing a request for redetermination.
( 2 ) *How to request an extension of timeframe.* If the 60 calendar day period in which to file a request for a redetermination has expired, an enrollee or a prescribing physician or other prescriber acting on behalf of an enrollee may file a request for redetermination and extension of time frame with the Part D plan sponsor. The request for redetermination and to extend the timeframe must— ( i ) Be in writing; and
( ii ) State why the request for redetermination was not filed on time.
( d ) *Withdrawing a request.* The person who files a request for redetermination may withdraw it by filing a request with the Part D sponsor.
( e ) *Dismissing a request.* A Part D plan sponsor dismisses a redetermination request, either entirely or as to any stated issue, under any of the following circumstances: ( 1 ) When the person or entity requesting a redetermination is not a proper party under § 423.580.
( 2 ) When the Part D plan sponsor determines the party failed to make out a valid request for redetermination that substantially complies with paragraph (a) of this section.
( 3 ) When the party fails to file the redetermination request within the proper filing time frame in accordance with paragraph (b) of this section.
( 4 ) When the enrollee or the enrollee's representative files a request for redetermination, but the enrollee dies while the request is pending, and both of the following criteria apply: ( i ) The enrollee's surviving spouse or estate has no remaining financial interest in the case.
( ii ) The enrollee's representative, if any, does not wish to pursue the request for coverage.
( 5 ) When a party filing the redetermination request submits a timely request for withdrawal of the request for a redetermination with the Part D plan sponsor.
( f ) *Notice of dismissal.* The Part D plan sponsor must mail or otherwise transmit a written notice of the dismissal of the redetermination request to the parties. The notice must state all of the following: ( 1 ) The reason for the dismissal.
( 2 ) The right to request that the Part D plan sponsor vacate the dismissal action.
( 3 ) The right to request review of the dismissal by the independent entity.
( g ) *Vacating a dismissal.* If good cause is established, a Part D sponsor may vacate its dismissal of a request for redetermination within 6 months from the date of the notice of dismissal.
( h ) *Effect of dismissal.* The dismissal of a request for redetermination is binding unless the enrollee or other party requests review by the IRE or the decision is vacated under paragraph (g) of this section.
[74 FR 1547, Jan. 12, 2009, as amended at 74 FR 65363, Dec. 9, 2009; 83 FR 16752, Apr. 16, 2018; 86 FR 6120, Jan. 19, 2021; 89 FR 30841, Apr. 23, 2024]