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WolfePack Wisdom

A comprehensive legal resource page with original commentary and key takeaways on critical topics impacting our clients industries.

Update to Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.

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

Medicare Advantage Plans must follow the Federal Administrative Appeal Process When Non- Contracted Providers Dispute the Overpayment Recoupments.

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