Wiki How to file complaints for Medicare Advantage denials

[mlovorn1]

Does anyone have experience in filing a complaint on Commercial payers that provide Medicare Advantage plans? I exhausted my appeals through the payer and I've called the state insurance commissioner, Medicare, CMS Helpdesk and OIG office and everyone says its not under their jurisdiction...Trying to navigate how to file a complaint if we feel the denial goes against CMS guidelines

 

[amyjph]

Have you involved the patient in the matter yet? Sometimes that route works better.

 

[CBLENNIE]

Does anyone have experience in filing a complaint on Commercial payers that provide Medicare Advantage plans? I exhausted my appeals through the payer and I've called the state insurance commissioner, Medicare, CMS Helpdesk and OIG office and everyone says its not under their jurisdiction...Trying to navigate how to file a complaint if we feel the denial goes against CMS guidelines

I work for a payer that offers MA plans (Part C coverage) and when a reconsideration request (appeal) is upheld in whole or in part we are required to automatically send the reconsideration request to Maximus (the Independent Review Entity for all Part C plans) for review of the adverse decision on the appeal.

You stated you exhausted your appeals through the payer, but have you gotten the decision letter from Maximus yet with their decision on the appeal. Below is the information on how long Maximus has to make their decision on the appeal depending on the type of appeal is under review:



If Maximus upholds in whole or in part the adverse decision, then the next step for the appellant is to file a request for a hearing with an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals (OMHA).

You can find this information on the CMS website under Reconsideration by Part C Independent Review Entity (IRE).

If you have any questions or need additional information don't hesitate to reach out to me directly.

 

[orthobiller2017]

I work for a payer that offers MA plans (Part C coverage) and when a reconsideration request (appeal) is upheld in whole or in part we are required to automatically send the reconsideration request to Maximus (the Independent Review Entity for all Part C plans) for review of the adverse decision on the appeal.

You stated you exhausted your appeals through the payer, but have you gotten the decision letter from Maximus yet with their decision on the appeal. Below is the information on how long Maximus has to make their decision on the appeal depending on the type of appeal is under review:

View attachment 7651

If Maximus upholds in whole or in part the adverse decision, then the next step for the appellant is to file a request for a hearing with an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals (OMHA).

You can find this information on the CMS website under Reconsideration by Part C Independent Review Entity (IRE).

If you have any questions or need additional information don't hesitate to reach out to me directly.

HI- does this apply to erroneous no authorization denials. We have two carriers that refuse to send to Maximus and per calling Maximus they state that providers cant initiate an appeal unless it was dismissed (which it wasnt-just ruled against)