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On August 3, 2022, the Centers for Medicare and Medicaid Services (“CMS”) released updated guidance regarding the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals, which is effective immediately.[1] Here are the highlights of the appeal process for Medicare Part C (“Medicare Advantage”) Plans: Non-contracted providers have the same appeal rights for Part C
On Friday, the Departments issued final rules for the No Surprises Act’s (“NSA”) independent dispute resolution (“IDR Process”). These final rules go into effect 60 days after the date of publication in the Federal Register and apply to plan years beginning on or after January 1, 2022.
Many Medicare Advantage Organizations (“MAOs”) are not contracted with providers. When an MAO enrollee presents to the provider for healthcare services, the provider verifies the enrollee’s coverage, obtains authorization where necessary, and renders the requisite services. The provider then submits a claim to the MAO for payment, and the MAO adjudicates payment. Nevertheless, in many