slide: Title Page

Title and Menu visited
- Title Page visited
- Menu
Introduction
- Introduction
- Navigating and Completing the Course
- Course Objectives
- Course Overview
Lesson 1: Basic Definitions
- Lesson 1 Basic Definitions
- Enrollee
- Dismissal
- Coverage Determination
- Appeal
- Appeals Procedures
- Redetermination
- Independent Review Entity
- Effectuation
- Grievance
- Review Questions
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 1: Basic Definitions
Lesson 2: Coverage Determinations
- Lesson 2: Coverage Determinations
- Coverage Determinations
- Coverage Determinations (continued)
- Coverage Determination Requests
- Coverage Determination Requests (continued)
- Appointment of Representative Form
- Adjudication Timeframe
- Adjudication Timeframe (continued)
- Adjudication Timeframe (continued 2)
- Adjudication Timeframe (continued 3)
- Adjudication Timeframe (continued 4)
- Adjudication Timeframe (continued 5)
- Plan Policies and Procedures
- Gathering Information
- Reasonable Outreach
- Involving Physician or Other Licensed Health Care Professionals in Review
- Notification
- Notification of Partially Favorable or Adverse Decisions
- Notification of Partially Favorable or Adverse Decisions (continued)
- Notification of Favorable Decisions
- Dismissal
- Dismissal (continued)
- Review Questions
- Review Question (1 of 3)
- Lesson 2 Review Question (2 of 3)
- Lesson 2 Review Question (3 of 3)
- You’ve completed Lesson 2: Grievances & Organization Determinations
Lesson 3: Appeals & Grievances
- Lesson 3: Appeals & Grievances
- 5 Appeals Levels
- First Appeal Level: Redetermination
- Redetermination: Making a Request
- Redetermination: Adjudication Timeframe
- Redetermination: Notification Requirements
- Redetermination: Adverse Decision Notification Requirements
- Redetermination: Favorable Decision Notification Requirements
- Redetermination: Dismissal
- Redetermination: Dismissal (continued)
- Second Appeal Level: Reconsideration
- IRE Reconsideration: Dismissal
- IRE Reconsideration: Dismissal (continued)
- 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
- Proper Effectuation: Favorable Plan Redeterminations
- Proper Effectuation: Favorable Decisions from Another Review Entity
- Grievances
- Grievances Resources
- Review Questions
- Review Question (1 of 3)
- Review Question (2 of 3)
- Review Question (3 of 3)
- You’ve completed Lesson 3: Appeals & Grievances
Lesson 4: Common Problems
- Lesson 4: Common Problems
- Common Problems
- Untimely or Inappropriate Effectuation
- Coverage Determinations or Appeals Requests Misclassified as Grievances
- Coverage Determinations or Appeals Requests Misclassified as Grievances (continued)
- Inappropriately Processing Appeals as Initial Coverage Determination Requests
- Sending Enrollees or Their Representatives Untimely or Inappropriate Notices
- Insufficient or Inaccurate Denial Notices
- Failure to Auto-Forward Untimely Cases to the IRE Appropriately
- Failure to Properly Oversee and Monitor Delegated Entities
- Review Questions
- 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 D Coverage Determinations, Appeals, & Grievances