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."
Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights. 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.
For additional information concerning Medicare managed care appeals notice requirements, including English and Spanish versions of the notices, click on the links in the "Related Links" below, or go to “Notices and Forms” using the link on the left navigation menu on this page.
Outreach to Providers for Information to Support Organization Determinations and Reconsiderations
On February 22, 2017, CMS released the HPMS memorandum entitled, “Updated Guidance on Outreach for Information to Support Coverage Decisions.” A copy of the memo is available in the “Downloads” section below. This memorandum provides clarifying information regarding CMS' expectations for Medicare Advantage Organizations to conduct outreach to providers when they do not have all necessary information to make a coverage decision. The next revision of Chapter 13 of the Medicare Managed Care Manual will be consistent with this guidance. The information included in the HPMS memorandum supersedes any conflicting guidance in the existing version of Chapter 13, and took effect upon release of the guidance.
Web Based Training Course Available for Part C
The course covers requirements for Part C organization determinations, appeals, and grievances found at 42 CFR Part 422, Subpart M and Chapter 13 of the Medicare Managed Care Manual. Complete details can be viewed on the "Guidance" page, using the link on the navigation menu on the left.
- Updated Guidance on Outreach for Information to Support Coverage Decisions [PDF, 118KB]
- 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, 180KB]
- Page last Modified: 05/08/2017 11:43 AM
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