Components: Grievances, coverage/organization determinations, and appeals for Medicare Advantage (MA) plans, Medicare cost plans, HCPPs, and stand-alone Part D plans.
Legal Status: The document provides clarity on existing requirements but does not have the force of law.
Key Sections
Introduction
Regulations: Based on 42 CFR Part 422 Subpart M and 42 CFR Part 423 Subparts M and U.
Objective: Address grievances, coverage determinations, and appeals.
Glossary
Terms such as Medicare Advantage (MA), Coverage Request, Initial Determination, Reconsideration, and Redetermination are defined.
Applicability to Employer-Sponsored Benefits
Part C: Managed care appeal procedures apply to all MA plan benefits.
Part D: Includes benefits offered under Employer/Union-Only Group Waiver Plans.
Claims Processing and Appeals
Cost Plans & HCPPs: Claims often processed as regular Part B claims except under specific conditions.
Appeals: Subject to specific appeals rules based on service settings.
General Responsibilities of the Plan
Medical Exigency Standard: Decisions made as per health needs.
Role of Medical Director: Responsible for clinical accuracy in decisions.
Delegation of Responsibilities: Possible with proper oversight.
Plan Communication: Procedures for determinations, appeals, and grievances must be clearly communicated to enrollees.
Adjudication Requirements
Timeliness Calculation: Specific start dates for calculating timeframes.
Notification: Considered delivered upon dispatch via mail or electronically.
Representatives
Filing on Behalf: Requirements for representative appointment.
Authority: Representatives have similar rights to enrollees in appeals.
Grievances
Classification: Difference between grievances, inquiries, and appeals.
Process: Establishment of procedures for timely resolution.
Coverage Determinations & At-Risk Determinations
Initial Determinations: Defined by payment decisions and service provision.
Part D: Includes specific coverage determination criteria.
Appeals Procedures
Reconsiderations & Redeterminations:
Level 1 Appeals: Overview of parties eligible to request.
Requirements for filing and processing.
Reconsiderations by Independent Review Entity
Level 2 Appeals: IRE processes and requirements for Part C and Part D.
Administrative Law Judge/Council Review
Further Appeals: ALJ, Council, and Federal Court reviews.
Amount in Controversy: Specific thresholds needed for further appeals.
Reopenings and Revising Determinations
Conditions: Guidelines for reopening decisions based on new evidence or errors.
Effectuation
Compliance: Requirements following appeal decisions.
Monitoring: Independent Review Entity monitoring of compliance.
Provider Notices
Hospital, SNF, HHA, CORF: Notification requirements for enrollees in hospital and care facilities.
Part C Data
Disclosure: Plans must disclose grievance and appeals data to enrollees upon request.
Appendices
Appendix 1: Overview of the Medicare Managed Care (Part C) Appeals Process.
Appendix 2: Overview of the Medicare Prescription Drug (Part D) Appeals Process.
Resources
Links to official regulations, notices, forms, and contact information for further guidance.