Member Grievance and Appeal

Overview

100

This is when a member is disputing the way that a claim or authorization processed

Appeals

200

When the member expresses dissatisfaction about something other than the way that a claim or medical/pharmacy authorization processed

A Grievance

300

This is the team that investigates and resolves member, representative, and provider Appeals and Grievances in accordance with CMS rules and regulations.

Resolution Team

400

These type of benefits aren't subject to Medicare appeals process. Disputes over these products and services are grievances.

Value-added items and services (VAIS) and complimentary benefits

500

This is when the member is disputing the way thta an authorization processed and standard appeal time frame could seriously jeopardize their life or health or ability to regain maximum function.

An expedited appeal

Call Procedures

100

Who has the authority to file a grievance or appeal for member. 

Member or Member's power of attorney (POA)

200

CMS require this form when someone other than the member submits a dissatisfaction or dispute on the member's behalf. 

Appointment of Representative (AOR) 

300

If a prior Grievance and Appeal was already submitted you would go to this mentor

Grievance or Appeal Status for Medicare

400

For this type of call you would thank the caller for taking time to share their experience, Document the case ID of the call and details, and share the info with your leader to share with the appropriate leader

Compliment Calls

500

Mentor tells us to use 'File an Appeal or Grievance Online Medicare and Medicaid" when offering these type of options.

Self-Service options

G&A Guidance Table

100

This is the mentor you would use for an initial appeal for a medical claim/authorization and Pharmacy claims

Appeals for Medicare

200

the Guidance Table directs you to this mentor when dealing with Fraud, waste and abuse

Healthcare Fraud, Waste, and Abuse Overview.

300

What mentor does the guidance table tell you to use for status of a Part B Drug appeals?

Part B Drug Appeal Initiation or Status Calls

400

If I am initiating a new grievance about an Automate call (VAT) calls what mentor would I refer to?

Do Not Call and Complaint Procedures

500

You would refer to this mentor when filing an initial grievance on disability and general discrimination.

Federal Non-Discrimination Inquiries, Complaints, and Grievance.

Verbal Grievance

100

This step helps us determine who is calling in about the grievance

Step 2

200

Step 2 tells us to do this when someone other than the member or POA is calling about a grievance. 

Advise the caller a verbal consent from the member is needed to file a grievance. 

300

This step has us review the grievance process and time frame requirements with the caller

Step 5

400

We don't send grievances for these types of callers to the Resolution team. These types of callers are not considered a member and do not have grievance rights. 

Unknown Callers

500

Per step 5 what mentor would you use to provide grievance process and time frame requirements for a Pharmacy drug Plan/PDP. Also applies to Part D coverage on MAPD plans.

Medicare Prescription Drug Plan(PDP) Grievance First Level Review.