Fillable Medicare Part D QIC Reconsideration Project Plan Contact (Medicare Part D Appeals)

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Medicare Part D QIC Reconsideration Project Plan Contact (Medicare Part D Appeals)

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The Medicare Part D QIC Reconsideration Project Plan Contact (Medicare Part D Appeals) form is 1 page long and contains:

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Country of origin: US
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V5.0
Medicare Part D QIC Reconsideration Project
Plan Contact Information Update Form
Part D Prescription Drug Appeals Late Enrollment Penalty Appeals
Report Contact
(Please be sure to check one, or multiple of the boxes above as applicable.)
Contract Number
(H/S/R/E ___ ___ ___)
*
Contract Name
Contract Type (PDP, Local CCP,
Demo, Regional CCP, Employer)
Mailing Address
Mail Stop
City
State
Zip Code
Secured Fax Number
Primary Contact Name
Primary Contact Phone #, ext.
Primary Contact Email
Alternate Contact Name
Alternate Contact Phone #, ext.
Alternate Contact Email
Effective Date of Change
The Part D Plan contact is the individual to whom all general appeal information is to be
sent by MAXIMUS Federal Services. If the Plan selects another individual at the Plan to
receive information about a specific case file that is submitted to MAXIMUS Federal
Services pursuant to an appeal, the Plan must list this individual on the Case File
Transmittal Form as the Plan contact person for that specific case.
*It is acceptable to list multiple Plan contract id numbers if the contacts and addresses
are the same.
Please e-mail this form with applicable contact changes to:
MedicarePartDAppeals@maximus.com
G Michelle Reed
Part D QIC Plan Liaison
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Medicare Part D QIC Reconsideration Project Plan Contact (Medicare Part D Appeals)

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Completed 31 January 2021

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