tci Medicare Compliance & Reimbursement - 2022 Issue Q3

Reader Questions: Know These Facts on Addressing Part C Grievances

Question: One of the providers in our Medicare Advantage (MA) plan received a grievance. We are confused. Do we appeal that? Is it a denial? North Carolina Subscriber Answer: First, know that a grievance is not a claims denial. A Part C grievance refers to a beneficiary’s complaint. “A grievance is an expression of dissatisfaction (other than an organization determination) with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested,” the Centers for Medicare & Medicaid Services (CMS) explains in MA guidance...

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