← Glossary · CMS & regulatory
Downgrade (expedited to standard)
When the sponsor declines to expedite a request and processes it as standard, with required notice to the enrollee and prescriber.
Auditors check the downgrade was proper and that the notice explains the 72-hour standard timeframe, the right to file an expedited grievance, and the right to resubmit an expedited request with the prescriber's support. The notice must also explain the sponsor's grievance process and timeframes.
Sources: CDAG protocol, Processing of Coverage Requests 2.5, p. 12; ODAG protocol, Universe Table 1, Column X, PDF p. 21; Processing of Coverage Requests 2.5, PDF p. 13.