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

September 16, 2022 | Andrea Greenblatt

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:

  1. Non-contracted providers have the same appeal rights for Part C claims as enrollees to certain appeals under the federal appeal regulations set forth at 42 CFR Part 422 Subpart M. 

  2. CMS incorporated its’ 2020 guidance to this update, which included examples where a non-contracted provider, who is the enrollee’s assignee, must be afforded full administrative appeals rights.[2]

  3. Even if the Plan partially pays for coverage, a non-contracted provider may request reconsideration under the Medicare administrative appeals process. Non-contracted providers do not need to receive a denial of coverage (i.e., zero payment) to request a reconsideration or to otherwise access the federal appeals process.

  4. If the Plan dismisses a level 1 appeal request (“Request for Reconsideration”), the non-contracted provider has the right to request an independent review entity (“IRE”) review of the Plan’s dismissal within 60 calendar days from the date of the Plan’s dismissal notice. In that case, the plan must forward the case file for dismissal to the IRE. Additionally, the Plan may vacate its own dismissal within 6 months of the date of the dismissal if good cause is presented by the non-contracted provider.

  5. The IRE’s dismissal of a level 2 appeal (“Request for IRE Reconsideration”) is binding unless the non-contracted provider requests review by the Administrative Law Judge (“ALJ”), or the decision is vacated by the IRE. Additionally, the non-contracted provider has the right to request that the IRE vacate the dismissal action. The IRE may vacate its own dismissal within 6 months of the date of the dismissal if good cause is established.

Well-versed in negotiating and navigating the Medicare Part C administrative appeal process for non-contracted providers, the Wolfe | Pincavage team guides providers, hospital systems, and physicians groups through every aspect of the appeals process.

[1] Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, Aug. 03, 2022.

[2] Non-Contract Provider Access to Medicare Administrative Appeals Process, CMS, Sept. 18, 2020.