Medicare Managed Care Appeals & Grievances
Guidance for changes and updates to updated Part C in Medicare Managed Care Appeals and Grievances.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 01, 2020
What's New
UPDATED PART C APPEALS GUIDANCE
August 3, 2022: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate the new Dismissal regulations, other revised provisions of CMS-4190, and clarifications of existing language. The updated guidance will be effective immediately. Questions related to the guidance or appeals policy may be submitted to the Division of Appeals Policy at https://appeals.lmi.org.
To access the guidance document, see the link to "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" in the “Downloads” section below.
May 3, 2022: The new Medicare Parts C & D IRE Decision Database can be located at https://www.cms.gov/qic-decision-search.
December 2021: CMS has developed frequently asked questions (FAQs) and model dismissal notices based on recent regulatory changes in CMS-4190-F2 related to dismissals of Part C organization determinations and reconsiderations and Part D coverage determinations and redeterminations, effective January 1, 2022.
The FAQs address common questions we have received from MA plans and Part D plan sponsors and is available in the “Downloads” section below.
The model dismissal notices are available on the "Notices and Forms" page, using the link on the left navigation menu on this page.
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 regarding Medicare managed care appeals and grievances can be submitted at: https://appeals.lmi.org
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.