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CMS posts Part C Training for Organizational Determinations, Appeals, and Grievances

The Centers for Medicare & Medicaid Services (CMS) has posted Web-Based Training (WBT) on the important Part C (Medicare Advantage) organizational determinations, appeals, and grievances.  You can link to the CMS-provided training at this link and the Medicare Managed Care Manual, Chapter 13, on Appeals and Grievances here.

Remember that when a service you want to provide is possibly or likely to be noncovered by a Medicare Advantage plan (aka Medicare Advantage Organization, or MAO), “a Medicare Advantage enrollee has always had the right under the statute and regulations to an advance determination of whether services are covered prior to receiving such services”.[i]

Important:

  • As we noted before in a prior WebNews item on this subject from June 2014, failure to ask for this “preservice organizational determination” might relieve the beneficiary of financial responsibility and any funds collected might have to be refunded.
  • An Advance Beneficiary Notice cannot be used for Part C beneficiaries.
  • It is important to check with each of the MAO’s you participate with to see what forms they might require and what process they are using for organizational determinations.

As always, if you need assistance, Corcoran Consulting Group can help.  Visit our website or call us to learn more.  You can link to our new App, Corcoran 24/7 via the links below.


[i] CMS letter to MAO.  Improper Use of Advance Notices of Non-coverage.  Link here.  Accessed May 31, 2016.

 

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