Medicare Managed Care Appeals & Grievances

What's New

UPDATED PART C APPEALS GUIDANCE

July 19, 2024: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate recent changes to 42 CFR § 422.566(d), to include certain terminology changes, to clarify who may act or be appointed as a representative, and to indicate that enrollees, their representatives, or providers on behalf of enrollees, have the right to voluntarily request plan approval on any service, item, or Part B drug which they believe are, or should be, covered by the plan. 

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.

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