Online PART D Information Center

PART D: Glossary

Appeal: A request to have the plan reconsider an adverse Organization Determination/denial. 2nd step in the appeal process and the first level of appeal. Also called request for reconsideration.

Independent Review Entity (IRE): group of health care professionals contracted by the Federal Government to review adverse organization determination/denials made by the Plan and upheld on appeal. The IRE makes a redetermination. 3rd step in the appeal process and the second level of appeal.

Administrative Law Judge (ALJ): when the IRE upholds the Plan’s denial/adverse decision, you or your appointed representative may request a review by the Administrative Law Judge. The 4th step in the appeal process and the 3rd level of appeal.

Medicare Appeals Council (MAC): can be requested if the ALJ upholds the adverse decision made IRE in part or in whole. This is the 5th step in the appeal process and the 4th level of appeal.

Federal Court: can be requested if the MAC upholds the adverse decision made by the ALJ and the amount contested is $1,090 or more. The Judge’s decision is the 6th step in the appeal process and the 5th level of appeal. The judge’s decision is final and you may not take the appeal any further.

Grievance: A written or verbal expression of dissatisfaction with the Plan, provider, plan operations, activities or behavior regardless of whether remedial action is requested.

Organization Determination: decision made by the plan or a contracted provider on MDCareAdvantage’s behalf to approve medically necessary care and services or approve payment for care and or services requested by you or a plan provider. A physician can only make denials. It is the first step in the appeal process.

Quality Improvement Organization (QIO): a group of health care professionals contracted
by the Federal Government to review hospital discharges for appropriateness and redetermination regarding discharge from an acute care hospital, skilled nursing/rehabilitation facility, physical therapy, home health services and ambulatory surgery facilities.