On August 3, CMS issued updates to Parts C & D Enrollee Grievance, Organization/Coverage Determination and Appeals Guidance, which is effective immediately. The updates incorporate new Dismissal regulations, other revised provisions of CMS-4190, and clarifications of existing language. Here are three key updates:
- CMS clarified that for the notice to be considered delivered by the plan on standard reconsiderations, verbal notice can be provided, however the written notice must still arrive within the applicable timeframe (either 30 days, or 44 days if case was extended). The three-day grace period after verbal notice for standard reconsiderations is no longer provided. For Part D redeterminations, the plan must notify the enrollee in writing of its redetermination as quickly as the enrollee’s health condition requires, but no later than seven calendar days from the date it receives the request for a standard redetermination.
- CMS clarified that non-contracted providers have the same appeal rights for Part C Claims Appeals as enrollees as a party to certain appeals under the appeal provisions set forth at 42 CFR Part 422 Subpart M.
- CMS clarified that a plan may vacate its own dismissal within six months of the date of the dismissal if good cause is presented by the enrollee. The plan’s decision is binding unless the enrollee or other party requests review by the independent review entity (IRE). The IRE decision is binding unless the party appeals to administrative law judge.
Contact ATTAC to see how these impact timeliness calculations and operational processes.