(a) Content of the request. The request for an ALJ hearing must be made in writing, except as set forth in paragraph (b) of this section. The request, including any oral request, must include all of the following:
(1) The name, address, telephone number, and Medicare health insurance claim number of the enrollee.
(2) The name, address, and telephone number of the appointed representative, as defined at § 423.560, if any.
(3) The appeals case number assigned to the appeal by the IRE, if any.
(4) The prescription drug in dispute.
(5) The plan name.
(6) The reasons the enrollee disagrees with the IRE's reconsideration.
(7) A statement of any additional evidence to be submitted and the date it will be submitted.
(8) A statement that the enrollee is requesting an expedited hearing, if applicable.
(b) Request for expedited hearing. If an enrollee is requesting that the hearing be expedited, the enrollee may make the request for an ALJ hearing orally, but only after receipt of the written IRE reconsideration notice. The ALJ hearing office must document all oral requests in writing and maintain the documentation in the case files. A prescribing physician or other prescriber may provide oral or written support for an enrollee's request for expedited review.
(c) When and where to file. Consistent with §§ 423.1972(a) and (b), the request for an ALJ hearing after an IRE reconsideration must be submitted:
(1) Within 60 calendar days from the date the enrollee receives written notice of the IRE's reconsideration.
(2) With the entity specified in the IRE's reconsideration.
(i) If the request for hearing is timely filed with an entity other than the entity specified in the IRE's reconsideration, the deadline specified in § 423.2016 for deciding the appeal begins on the date the entity specified in the IRE's reconsideration receives the request for hearing.
(ii) If the request for hearing is filed with an entity, other than the entity specified in the IRE's reconsideration, the ALJ hearing office must notify the appellant of the date of receipt of the request and the commencement of the adjudication timeframe.
(d) Extension of time to request a hearing.(1) Consistent with § 423.1972(b), if the request for hearing is not filed within 60 calendar days of receipt of the written IRE's reconsideration, an enrollee may request an extension for good cause.
(2) Any request for an extension of time must be in writing or, for expedited reviews, in writing or oral. The ALJ hearing office must document all oral requests in writing and maintain the documentation in the case file.
(3) The request must give the reasons why the request for a hearing was not filed within the stated time period, and must be filed with the entity specified in the notice of reconsideration.
(4) If the ALJ finds there is good cause for missing the deadline, the time period for filing the hearing request will be extended. To determine whether good cause for late filing exists, the ALJ uses the standards set forth in §§ 405.942(b)(2) and (b)(3) of this chapter.
(5) If a request for hearing is not timely filed, the adjudication period in § 423.2016 begins the date the ALJ grants the request to extend the filing deadline.
Title 42 published on 2012-10-01
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