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Guidance

This section provides information important to plans, providers and beneficiaries receiving benefits through a Part C Medicare health plan.  Included below under "Downloads" is the Part C Managed Care Appeals Flow Chart and Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.  A link to additional guidance applicable to the grievance, organization determination, and appeals processes is under "Related Links."

WEB BASED TRAINING COURSE AVAILABLE FOR PART C AND PART D

The Centers for Medicare & Medicaid Services (CMS) has developed two web-based training (WBT) courses.  The courses cover requirements for Part C organization determinations, appeals, and grievances, and Part D coverage determinations, appeals, and grievances, and information found at 42 CFR Part 422, Subpart M (Part C), 42 CFR Part 423, Subparts M and U (Part D), and Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.

Specifically, the courses include:

  • A pre-assessment;
  • Part C and Part D definitions;
  • Requirements for Part C organization determinations, reconsiderations, and grievances;
  • Requirements for Part D coverage determinations, redeterminations, and grievances;
  • Common audit findings and frequently asked questions;
  • A post-assessment knowledge check and certificate of completion; and
  • The opportunity to earn Continuing Education (CE) Credits.

CMS recommends that plans identify appropriate personnel in their organizations to review the WBT courses.  These courses are designed for compliance officers, staff involved with initial coverage decisions, appeals and grievances, and customer service representatives.  Although this training is not mandatory, CMS strongly suggests that compliance officers incorporate these courses into their existing in-house training protocols and use the certificate to track course completion within their organizations.  

Each course takes approximately 60 minutes to complete.  Both courses were created in conjunction with the Medicare Learning Network (MLN).  As such, each WBT course offers:

  • 1 CEUs by the International Association for Continuing Education and Training (IACET)
  • 1 AMA PRA Category 1 Credit™ by the Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Statements AMA PRA Category 1 Credit™ is a trademark of the American Medical Association

To access the courses, you will need to register and create an account using the following instructions:  

1. Go to http://go.cms.gov/MLNProducts on the CMS website.
2. In the secondary navigation menu, select "Events & Training," then select "Web-Based Training" from the drop down selection.
3. Follow the directions on the page to create a training account.
4. Once your account is activated you may enter the LMS through the MLN LMS login page.

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