slide: Title Page

Title and Menu visited
- Title Page visited
- Menu
Introduction
- Introduction
- Navigating the Course
- Course Objectives
- Course Overview
Lesson 1: Basic Definitions
- Lesson 1: Basic Definitions
- Enrollee
- Dismissal
- Organization Determination
- Appeal
- Appeals Procedures
- Reconsideration
- Independent Review Entity
- Effectuation
- Grievance
- Lesson 1: Review Questions
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 1
Lesson 2: Grievances & Organization Determinations
- Lesson 2: Grievances & Organization Determinations
- Organization Determinations
- Organization Determination Requests
- Appointment of Representative Form
- Timeframe: Pre-Service Requests
- Timeframe: Payment Requests
- Organization Determination Request Timeframes
- Notification of Favorable Decisions
- Dismissal
- Dismissal (continued)
- Notification of Partially Favorable or Adverse Decisions
- Involving a Physician or Other Licensed Health Care Professional in Review
- Non-Contract Provider Notification Requirements
- Grievances
- Grievances Resources
- Lesson 2 Review
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 2
Lesson 3: Appeals
- Lesson 3: Appeals
- 5 Appeals Levels
- First Appeal Level: Medicare Advantage Plan Reconsideration
- MA Plan Reconsideration: Making a Request
- MA Plan Reconsideration: Adjudication Timeframe
- MA Plan Reconsideration: Failure to Meet Adjudication Timeframe
- MA Plan Reconsideration: Notification Requirements
- Reconsideration: Dismissal
- Reconsideration: Dismissal (continued)
- IRE Reconsideration: Dismissal
- IRE Reconsideration: Dismissal (continued)
- Enrollee Liability for Plan-Provided or Plan-Referred Services
- Beneficiary and Family Centered Care Quality Improvement Organization: Expedited Review for Inpatient Hospital Discharges
- Timeline: Expedited Review for Inpatient Hospital Discharges
- Expedited Review for Comprehensive Outpatient Rehabilitation Facilities, Home Health Agencies, and Skilled Nursing Facility Services
- Timeline: Expedited Review for CORFs, HHAs, and SNF Services
- Outreach
- Third Appeal Level: Office of Medicare Hearings and Appeals Administrative Law Judge Hearing or Attorney Adjudicator Review
- Fourth Appeal Level: Medicare Appeals Council (Council) Review
- Fifth Appeal Level: Federal District Court Review
- Lesson 3 Review
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 3
Lesson 4: Common Problems
- Lesson 4: Common Problems
- Common Problems
- Untimely or Inappropriate Effectuation
- Sending Enrollees or Their Representatives Untimely or Inappropriate Notices
- Denial Notices That Don’t Have the Required Language or Aren’t Specific to the Case
- Failure to Conduct Proper Outreach Before Making a Decision
- Inappropriate Use of 14-Calendar-Day Extension
- Failure to Properly Address and Resolve Grievances
- Organization Determinations or Reconsiderations Misclassified as Grievances
- Lesson 4 Review
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 4: Common Problems
Return to Menu
- Return to Menu

Part C Organization Determinations, Appeals, & Grievances