Medicare Managed Care Appeals & Grievances

What's New

5/1/2026:  Effective May 1, 2026, C2C Innovative Solutions, Inc. (C2C) is the Part C IRE. The former Part C IRE, MAXIMUS, will continue to process appeal requests received on or before April 30, 2026. Appeal requests received on or after May 1, 2026, will be processed by C2C. There will be a short period of time when both MAXIMUS and C2C will be issuing decisions.

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.

Questions?

Questions regarding organization determinations, appeals and grievances can be submitted at: https://appeals.lmi.org