MEDICARE GRIEVANCES AND APPEALS
A PRIMER
Prepared for Disability Law Colorado
Medicare Medicaid Advocate Program
March 2016
Version 5: Mar 10, 2016
Notice: This Primer has been prepared for the internal use of Disability Law Colorado and the Medicare-Medicaid Advocate; it may be shared with business partners. The document is to be considered supplemental guidance to the law, rules and policies set forth by the Centers for Medicare & Medicaid Services on Medicare grievances and appeals.
Medicare Grievances and Appeals Primer
Introduction: This document has been prepared for the Medicare-Medicaid Advocate, Regional Care Collaborative Organization (RCCO) Customer Service Representatives, Care Coordinators and Advocates who want to assist an Accountable Care Collaborative: Medicare-Medicaid Program Enrollee with a MEDICARE Issue. This guide addresses MEDICARE’S FEE-FOR-SERVICE OR ORIGINAL MEDICARE program, only. It does NOT include guidance for persons with Medicare Advantage (Part C) nor does it include information about the Colorado Medicaid appeals program. (Links to information on Medicare Advantage Appeals and Colorado Medicaid Appeals are shown below.) This document is an extract from CMS “official” policy and is intended only as a guide to help explain the basics of the Medicare grievance and multi-level appeal processes. It summarizes key information about timeframes, what kind of documentation and what dollar levels might apply to each case. Pertinent sources on the CMS.gov website are included throughout the document.
Members of Colorado’s Accountable Care Collaborative: Medicare-Medicaid Program keep their full benefits under both Medicare and Medicaid. Generally, Medicare pays for covered health services first; Medicaid is secondary payer and covers services not included in Medicare; such as transportation for medical appointments. The Regional Care Collaborative Organizations’ staff may be the first contact by the member with a Medicare grievance or a denied claim for payment that could be or should be appealed. These guidelines are provided to assist RCCO staff or others who may be supporting the member to understand the basics of the Medicare grievance and appeals process.
