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Medicare health plans, which include Medicare Advantage (MA) plans – such as Health Maintenance Organizations, Preferred Provider Organizations, Medical Savings Account plans and Private Fee-For-Service plans – Cost Plans and Health Care Prepayment Plans, must meet the requirements for grievance and appeals processing under Subpart M of the Medicare Advantage regulations. For a detailed discussion of the Medicare managed care grievance and appeals processes, click on the link below to "Chapter 13 - Medicare Managed Care Manual" under "Downloads." If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination. Additionally, Medicare health plan enrollees receiving covered services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast, or expedited, review if they think their Medicare-covered services are ending too soon. Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights. For additional information concerning Medicare managed care appeals notice requirements, including Spanish versions of the notices, click on the links in the "Related Links Inside CMS" below. English and Spanish versions of the expedited and denial notices listed below expire on October 31, 2013. Plans were to begin using the updated versions of these notices no later than February 28, 2011. The updated notices may be accessed by clicking on the links under "Related Links Inside CMS" below. Please note: There are new draft expedited notices currently in the OMB Paperwork Reduction Act approval process. The draft CMS 10123-24 (Notice of Medicare Non-Coverage) combines the current CMS 10123-24 with the CMS 10095 and will serve as one set of notices for beneficiaries in Original Medicare and enrollees of Medicare health plans. The draft combined notice may be accessed by clicking on the last link under "Related Links Inside CMS" below.
Page Last Modified: 10/28/2011 9:33:31 AM
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