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    • How to Request Review of Plan Dismissal
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    • CMS Medicare Parts C IRE Decision Database
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Medicare Advantage Appendix

The Medicare Advantage Appendix contains instructions and forms for health plans to use when communicating with C2C about reconsideration appeals and related activities.

Medicare Advantage Appendix

Individual Forms

  • Dismissal Case File Data Form
  • New Case File Transmittal Cover Sheets for IRE Review of Plan Dismissal Case Files Submitted to IRE Outside of the QIC Appeals Portal
  • Key Plan Organizational Contact Form
  • New Case File Transmittal Cover Sheets for Reconsiderations Submitted to IRE Outside of the QIC Appeals Portal
  • Plan Reopening Request Form
  • Plan Response to IRE Request for Additional Documentation Transmittal Cover Sheet
  • Plan Submission of Additional Information Authorizing Coverage or Payment for an Item, Service, or Part B Drug Subsequent to the Plan Submission of the Case and Case File to the IRE for Processing of the IRE Reconsideration
  • Reconsideration Background Data Form
  • Statement of Compliance Form – Administrative Law Judge (ALJ) Decision
  • Statement of Compliance Form – Medicare Appeals Council (MAC) Decision
  • Statement of Compliance Form-IRE Reconsideration Decision
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