Grievances, Organization Determinations and Appeals

  1. Law
  2. CFR 42
  3. Public Health
  4. Centers for Medicare & Medicaid Services, Department of Health and Human Services
  5. Medicare Program
  6. Medicare Advantage Program
  7. Grievances, Organization Determinations and Appeals

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Section
422.560

Basis and scope.

Section
422.561

Definitions.

Section
422.562

General provisions.

Section
422.564

Grievance procedures.

Section
422.566

Organization determinations.

Section
422.568

Standard timeframes and notice requirements for organization determinations.

Subject_group

Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans

Section
422.570

Expediting certain organization determinations.

Section
422.572

Timeframes and notice requirements for expedited organization determinations.

Section
422.574

Parties to the organization determination.

Section
422.576

Effect of an organization determination.

Section
422.578

Right to a reconsideration.

Section
422.580

Reconsideration defined.

Section
422.582

Request for a standard reconsideration.

Section
422.584

Expediting certain reconsiderations.

Section
422.586

Opportunity to submit evidence.

Section
422.590

Timeframes and responsibility for reconsiderations.

Section
422.592

Reconsideration by an independent entity.

Section
422.594

Notice of reconsidered determination by the independent entity.

Section
422.596

Effect of a reconsidered determination.

Section
422.600

Right to a hearing.

Section
422.602

Request for an ALJ hearing.

Section
422.608

Medicare Appeals Council (Council) review.

Section
422.612

Judicial review.

Section
422.616

Reopening and revising determinations and decisions.

Section
422.618

How an MA organization must effectuate standard reconsidered determinations or decisions.

Section
422.619

How an MA organization must effectuate expedited reconsidered determinations.

Section
422.620

Notifying enrollees of hospital discharge appeal rights.

Section
422.622

Requesting immediate QIO review of the decision to discharge from the inpatient hospital.

Section
422.624

Notifying enrollees of termination of provider services.

Section
422.626

Fast-track appeals of service terminations to independent review entities (IREs).