Fillable CASE FILE TRANSMITTAL FORM PART D Q.I.C. LATE (Medicare Part D Appeals)

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CASE FILE TRANSMITTAL FORM PART D Q.I.C. LATE (Medicare Part D Appeals)

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PART D Q.I.C. LATE ENROLLMENT PENALTY (L.E.P.)
RECONSIDERATION
CASE FILE TRANSMITTAL FORM
Name of Part D Plan:
Date on Late Enrollment Penalty Notice to Enroll
ee (Chapter 4, Exhibit 2):
Enrollee Name:
Enrollee Health Insurance Card Number/ M
edicare Claim Number:
Date of Birth :
Enrollee Address:
Telephone Number:
Enrollee requires the Reconsideration Notice in a language other than English?
No Yes e needed: Languag
Part D Plan Information
• Plan Type
• PDP (S#) MA-PD (H or R#) ost C Employer Sponsored (E#)
• Plan Contract Number: Enter 4 digit C.M.S. Plan Number:
• Plan Identification Number:
• Plan Contact Representative and Title:
• Contact Phone Number:
• Fax Number:
• Email Address:
• Plan Address:
Is the Enrollee receiving a Low-Income Subsidy (L.I.S.): Yes No
Part D Q.I.C. L.E.P. Reconsideration Case File Transmittal Form Page 1 of 3
Version 3.1
S#
Plan Level Late Enrollment Penalty (L.E.P.) Information
L.E.P. Determination:
• Enrollee’s Entitlement Date to Medicare Part D:
• Enrollee’s Part D Initial Enrollment Period (I.E.P.):
• From To
• Date on Beneficiary Declaration of Prior Prescription Drug Coverage, if applicable (Chapter 4, Exhibit
1D):
• Date Beneficiary Declaration of Prior Prescription Drug Coverage was received by Plan, if applicable:
• Dates Beneficiary Attested to Having Prior Creditable
Prescription Drug Coverage: From To
• Entity (i.e. Employer/Group/
P
lan):
• Dates without Creditable P r
escription Drug Coverage:
• From To
• Number of Months NOT Covered for Prescription Drug
Coverage Reported to Centers for Medicare & Medicaid (C.M.S.):
L
.E.P. Dismissal Information (if applicable)
D
ate L.E.P. rescinded:
D
ate Beneficiary notified of L.E.P. rescission:
Part D Q.I.C. L.E.P. Reconsideration Case File Transmittal Form Page 2 of 3
Version 3.0
Part D Q.I.C. L.E.P. Reconsideration Case File Transmittal Form Page 2 of 3
Version 3.0
Part D Q.I.C. L.E.P.
Reconsideration Case File Transmittal Form Page 2 of 3
Version 3.0
Part D Q.I.C. L.E.P. Reconsideration Case File Transmittal Form Page 2 of 3
Version 3.1
• Enrollee LEP Notification Date:
Exhibits
Instructions:
Label applicable exhibits with the letters provided below and place them in order by letter. Check box with
exhibits provided.
Procedural Documents
A. Case Narrative cover page that presents an overview of the appeal. Describe the issue on
appeal; identify all relevant information (optional)
B. Beneficiary Declaration of Prior Prescription Coverage
C. Letter Informing Beneficiary of Late Enrollment Penalty
D. Other (describe or list below additional exhibits the Plan considers important)
Evidentiary Documents
E. Application for Enrollment in Part D Plan
F. Notice Informing Beneficiary of Part D Enrollment Effective Date
G. B.E.Q/M.A.R.x. Screen verifying enrollee’s Part D Entitlement, Part D Plan Enrollment and
Creditable Prescription Drug Coverage History
H. Notice of L.E.P. amount reported to Part D plan by C.M.S.
I. Evidence of Special Circumstances (such as proof an enrollee lived abroad and did not reside in
a Part D service area after his/her Part D initial enrollment period)
Part D Q.I.C. L.E.P. Reconsideration Case File Transmittal Form Page 3 of 3
Version 3.1
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CASE FILE TRANSMITTAL FORM PART D Q.I.C. LATE (Medicare Part D Appeals)

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Completed 31 January 2021

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