CMS’ Proposed Addendum to Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On July 7, 2020, the Centers for Medicare and Medicaid Services (CMS) distributed a draft addendum to address changes to Unified Appeal and Grievance processing for Integrated D-SNPs in the Parts C and D Enrollee Grievances, Organization/Coverage, Determinations, and Appeals Guidance. CMS notes that rules implementing unified grievances and appeals apply only to fully integrated dual eligible special needs plans (FIDE SNPs) and highly integrated dual eligible special needs plans (HIDE SNPs) referred to as “applicable integrated plans.” CMS included a list of states that may meet these requirements, but plans should contact CMS if they believe they may meet the integration criteria in the regulations. CMS requested comments on the proposed changes by August 7, 2020.

The addendum is a supplement to the current MA and Part D Appeal and Grievance guidance, and each addendum section aligns to the same section in the chapter. Noteworthy changes are summarized below. 

Section 10.1.a-10.6.a Introduction 

CMS added terms, applicable integrated plans, integrated organization determination and integrated reconsideration, and guidance that Medicaid requirements must be considered before finding a request invalid for dismissals. Also added were plan responsibilities for providing the enrollee the opportunity to present evidence and ensuring that no punitive action is taken against providers requesting or supporting integrated organization determination and integrated reconsideration. Finally, CMS added requirements to ensure that all comments, documents, and records are considered before making a determination and that applicable integrated plans must review Medicaid information as part of its monitoring procedures and updates to state Quality strategy. 

Section 30.a-30.3.1a Integrated Grievances 

CMS added that these must be reviewed by someone with appropriate clinical expertise if reviewing a denial of expedited resolution of integrated appeals or reviewing grievances regarding clinical issues. In addition, CMS clarified plan responsibilities for non-Part D and excluded drugs that may be available under Medicaid coverage. They added that integrated grievances can be filed at any time, so there are no timely filing limits. Plans must still meet the requirements for QIO and IRE reviews of termination of services from providers and hospital discharges, as well as for Medicaid-covered benefits. Plans must also comply with any state Medicaid quality of care requirements. 

Section 40.1a-40.12a Part C Integrated Organization Determinations 

CMS clarified who may request an initial determination, which includes providers that have not waived the ability to seek payment from the enrollee or are providing treatment to the enrollee. CMS stated that the provider may, after notifying the enrollee, request a standard or expedited pre-service request. Integrated organization determinations must be reviewed by a physician or other appropriate healthcare professional with knowledge of Medicare and Medicaid coverage criteria before the applicable integrated plan issues the integrated organization determination. 

Payment requests may be expedited and are not to be treated differently than non-payment requests for expedited integrated determinations. Plans should apply the same process to assess a request to expedite a payment as they to do assess requests to expedite non-payment cases. In addition, CMS included instructions on notification requirements for payment denials where there is no member liability, indicating that plans must send the enrollee a notice of the denial that includes that there is no member liability. 

Section 50.1a50.10.a Level 1 Integrated Appeal 

If the provider requests that the benefits continue while the integrated appeal is pending, the provider must obtain the written consent of the enrollee to request the integrated appeal. In addition, plans must accept verbal requests for expedited and standard appeals and upon request, and integrated plans must provide the enrollee’s complete case file free of charge and in advance of making the integrated reconsideration decision. Expedited Extensions may only occur if the enrollee requests the extension, or the extension is justified and in the enrollee’s interest, and there is need for additional information and a “reasonable likelihood that receipt of such information would lead to approval of the request, if received.” For denials of expedited appeals, the enrollee must be notified within 2 days of the denial.  They may be notified verbally, but written notice must be provided within 2 days of the verbal notice. Denial Notices must be sent and include language that the case was forwarded to the Part C IRE. 

Other Key Updates 

CMS also added in a new section 50.13 Continuing Benefits While an Integrated Reconsideration Is Pending, which applies to cases where an enrollee, their representative, or their provider is appealing an applicable integrated plan’s decision to reduce, terminate, or suspend previously authorized Medicare Part C or Medicaid covered services or items. This section should be carefully reviewed as it includes information on the timeframe for making these requests and the requirements to note when a plan must continue to provide service and when they are not financially responsible for services. 

Section 90.a Effectuation includes information about timelines for reversal effectuation and requires that the disputed services are authorized or provided promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. 


Plans should carefully review the addendum and provide comments to CMS by the deadline of August 7th, while making changes to plan policy as needed. 

Still feeling unsure about the potential updates? GHG assists plans in implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.