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Medicare Managed Care Appeals & Grievances

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" below.  


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 are listed on the "Guidance" page (select "Guidance" link on the navigation menu found at the left side of this page).