Medicare Managed Care Appeals & Grievances

What's New

UPDATED PARTS C and D APPEALS GUIDANCE

11/20/2024: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate the regulatory change in the timeframe to submit an appeal from 60 calendar days to 65 days calendar days from the date of the notice.  The NOMNC has been modified to reflect regulations providing enrollees additional fast-track appeal rights when they untimely request an appeal to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or still wish to appeal after they end services on or before the planned termination date.  Additionally, DENC instructions have been updated to include a new element for health plans to complete.

The updates will be effective 01/01/2025. 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.

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