Medicare Managed Care Appeals & Grievances
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.
Issuance of Revised NOMNC and DENC, FORM CMS-10123 and CMS-10124
CMS is issuing a new combined Notice of Medicare Non-Coverage. This notice will replace the CMS 10123 (Original Medicare notice) and the CMS 10095 (Medicare Advantage notice).
This combined notice retains the form number of the current Original Medicare Notice (CMS 10123) and the name of the MA notice (Notice of Medicare Non-Coverage, or NOMNC).
CMS also is issuing a new Detailed Explanation of Non-Coverage, or DENC, with the form number CMS 10124.
Providers have a 60 day grace period to begin using the new combined notices.
To view the new, combined notices, click on the "Expedited Notices (NOMNC and DENC) - English and Spanish" link in the "Related Links Inside CMS" below.
- Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) [PDF, 426KB]
- Managed Care Appeals Flow Chart [PDF, 83KB]
- Page last Modified: 04/17/2013 10:30 AM
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