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 and appeals processing under Subpart M of the Medicare Advantage regulations.  For a detailed discussion of the Medicare managed care grievance and appeals processes, click on the link below to "Chapter 13 - Medicare Managed Care Manual" under "Related Links Inside CMS."

If a Medicare health plan decides to deny, discontinue or reduce services or payments, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination.  Additionally, Medicare health plan enrollees receiving services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast appeal if they think their Medicare-covered services are ending too soon.  Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare's fast appeals process.  

For additional information regarding the Medicare managed care appeals process and Medicare managed care notice requirements, click on the links in the "Downloads" section and the "Related Links Inside CMS" below.

For additional information regarding Medicare inpatient hospital appeals and notice requirements, click on  "Important Message Message from Medicare About Your Rights" under the "Related Links Inside CMS" below.

Downloads
Notice of Medicare Non-Coverage (NOMNC) [pdf, 23KB] Instructions for NOMNC [pdf, 26KB] Detailed Explanation of Non-Coverage (DENC) [pdf, 25KB] Instructions for DENC [pdf, 15KB] Provider Education for Fast-Track Appeals [pdf, 20KB] Notice of Denial of Payment (NDP) [pdf, 92KB] NDP Instructions [pdf, 27KB] Notice of Denial of Medical Coverage (NDMC) [pdf, 102KB] NDMC Instructions [pdf, 24KB] Notices - MS Word [zip, 54KB]
Related Links Inside CMS
An Important Message from Medicare About Your Rights Cost Plan Guidance Chapter 13 - Medicare Managed Care Manual [PDF, 764KB] Part D Enrollment Guidance
Related Links Outside CMS
MAXIMUS Federal (formerly MAXIMUS CHDR) - CMS' Independent Review Entity

Page Last Modified: 07/17/2008 12:49:53 PM
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