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Medicare Managed Care Appeals & Grievances

What's New

UPDATED PART C APPEALS GUIDANCE

February 22, 2019: As part of an initiative to streamline the Part C and Part D appeal and grievance processes, CMS has merged Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one Parts C & D appeals guidance document. The combining of these chapters will better align Part C and Part D appeals policy, identify key differences between the two, provide clearer interpretation of current policy, and update guidance based on the Part C and D 2019 regulation.

To access the guidance document and a list of frequently asked questions, see the links to, "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" and “Part C & D Appeals Guidance Frequently Asked Questions (FAQs),” in the in "Downloads" section below.

 

Overview

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, organization determination, and appeals processing under the MA regulations found at 42 CFR Part 422, Subpart M.  For more information regarding grievances and various levels of appeal, please see the links on the left navigation menu on this page. Additional guidance is also in the "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance," in the “Downloads” section below.


Web Based Training Course Available for Part C

The course covers requirements for Part C organization determinations, appeals, and grievances. Complete details can be accessed on the "Training" page, using the link on the left navigation menu on this page.