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Sample
Report
(Appendix
2)
Medicare
Appeals and
Quality
of Care Grievances
Organization
X
April
1, 2006 to March 31, 2007
SAMPLE REPORT
(Appendix 2)
MEDICARE APPEALS AND
QUALITY OF CARE
GRIEVANCES
XYZ ORGANIZATION
April
1, 2006 to March 31, 2007
|
What
kind of information is this?
|
When
you ask for it, the government requires (XYZ
Organization)
X
to provide you with reports that describe what
happened to
formal complaints that (XYZ Organization)
X
received from their Medicare members. There are two types of
formal complaints: Appeals
and Grievances.
Medicare
members have the right to file an appeal or grievance with their
Medicare Advantage organization.
The next few pages contain information about the appeals
and
quality of care
grievances
that (XYZ Organization)
X
received between April 1, 2006, and March 31, 2007.
Each
organization will have different numbers of appeals and quality
of care grievances, and these numbers can mean different things.
For example, an organization might have a small number of appeals
and quality of care grievances because the organization talks
with members about their concerns and agrees to find solutions.
Or an
organization might have a small number of
appeals
and quality of care grievances because its members are not aware
of their right to file an appeal or grievance.
|
How
big is (XYZ
Organization)?
X?
|
(XYZ Organization)
X
has about 88,000 Medicare members.
(line
3 on the attached report)
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|
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Page 1
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Appeals Information beginning on Page 2
Quality of Care
Grievance Information on Page 6
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INFORMATION ON MEDICARE
APPEALS
April
1, 2006 To March 31, 2007
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What is an appeal?
|
An appeal is a formal complaint about (XYZ Organization)'s
decision not to pay for, not to provide, or to stop an item or
service that a Medicare member believes she/he needs.
If a member
cannot get an item or service that the member feels she/he needs,
or if the organization has denied payment of a claim for a
service the member has already received, the member can appeal.
For example, a member might appeal (XYZ Organization)'s
decision to stop physical therapy, to deny a visit to a
specialist, or to deny payment of a claim.
|
How many appeals did (XYZ
Organization) receive?
|
(XYZ Organization) received 174 appeals from its Medicare
members. About 2 out of every 1,000 Medicare members appealed
(XYZ Organization)'s decision not to pay for or provide,
or to stop a service that they believed they needed.
(lines 2 and 4 on the attached report)
|
How many appeals did (XYZ
Organization) review?
|
(XYZ Organization) reviewed 157 appeals during this time
period.
(lines 5
through 8 on the attached report)
|
What happened?
|
From the 174 appeals it received from its members:
(XYZ
Organization) decided to pay for or to provide all services
that the member asked for 41% of the time.
(XYZ
Organization) decided not to pay for or to provide the
services that the member asked for 49% of the time.
M
Page 2
edicare members withdrew their request before (XYZ
Organization) issued a decision 10% of the time.
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|
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Page
21
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Expedited or “Fast” Appeals
Information beginning
on
Page 32
Quality
of Care Grievance Information on Page 6
|
Information
on Medicare Appeals
April
1, 2006 to March 31, 2007
What
is an appeal?
|
An
appeal is a formal complaint about Organization
X's
decision not to pay for, not to provide, or to stop an item or
service that a Medicare member believes she/he needs.
If
a member cannot get an item or service that the member feels
she/he needs, or if the organization has denied payment of a
claim for a service the member has already received, the member
can appeal. INFORMATION
ON EXPEDITED OR “FAST” APPEALS
April
1, 2006 to March 31, 2007For
example, a member might appeal
Organization X's
decision to stop physical therapy, to deny a visit to a
specialist, or to deny payment of a claim.
|
What is a “fast”
or expedited appeal?How
many appeals did Organization
X
receive?
|
Organization
X
received
174 appeals from its Medicare members. About 2 out of every
1,000 Medicare members appealed Organization
X's
decision not to pay for or provide, or to stop a service that
they believed they needed.
(lines
2 and 4 on the attached report)
A Medicare member can request that
(XYZ Organization)
review
the member's appeal quickly if the member believes that his or
her health could be seriously harmed by waiting for a decision
about a service. This is called a request for an expedited
or
“fast”
appeal.
(XYZ
Organization) looks at each request and decides whether a
“fast” appeal is necessary. By law, (XYZ
Organization) must consider an appeal as quickly as a
member's health requires. If (XYZ Organization)
determines that a “fast” appeal is necessary, it must
notify the Medicare member as quickly as the member's health
requires but no later than 72 hours.
|
How
many “fast”
appeals
did XYZ
Organization
receive?
X
review?
|
(XYZ Organization)
received 20 requests for "fast” appeal from its
Medicare members.
X
reviewed
157 appeals during this time period.
(lines
145
through 168
on the attached report)
|
What
happened?
|
When a member requested a “fast” review, (XYZ
From
the 174
appeals it received from its members:
Organization)
agreed that a “fast” review was needed 75
X
decided
to pay for or to provide all services that the member asked for
41%
of the time.
(XYZ Organization)
did
X
decided
not agree to a “fast” review 25to
pay for or to provide the services that the member asked for 49%
of the time. This number may include requests by
members who the organization may not have believed were in danger
or might suffer serious harm.
M
Page 2
edicare members withdrew their request before Organization
X
issued
a decision 10%
of the time.
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|
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Page 3
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Independent Review of Appeals on Page 4
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INFORMATION ON
INDEPENDENT REVIEW
April
1, 2006 to March 31, 2007
|
What is Independent Review
of an appeal?
|
After a member has sent an appeal to (XYZ Organization),
if the organization continues to decide that it should not pay
for or provide all services that the member asked for, (XYZ
Organization) must send all of the information about the
appeal to an independent review entity (IRE) that contracts with
Medicare, not with (XYZ Organization).
An
independent review provides an opportunity for a new, fresh look
at the appeal outside of the organization. CMS’ IRE goes
over all of the information from (XYZ Organization) and
can consider any new information.
If the IRE
does not agree with (XYZ Organization)'s decision, (XYZ
Organization) must provide or pay for the services that the
Medicare member requested.
There may be
several reasons why the IRE decides to agree with either the
Medicare member or (XYZ Organization). For example, the
IRE may disagree with (XYZ Organization) because the IRE
may have had more information about the appeal.
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|
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Page
42
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Independent Review ContinuedExpedited
or “Fast” Appeals Information
on Page 53
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Information
on Expedited or “Fast” Appeals
April
1, 2006 to March 31, 2007
INFORMATION ON
INDEPENDENT REVIEW
April
1, 2006 to March 31, 2007What
is a “fast” or expedited appeal?
|
A
Medicare member can request that Organization
X
review
the member's appeal quickly if the member believes that his or her
health could be seriously harmed by waiting for a decision about a
service. This is called a request for an expedited
or
“fast”
appeal.
Organization
X's
looks
at each request and decides whether a “fast” appeal is
necessary. By law, Organization
X
must
consider an appeal as quickly as a member's health requires. If
Organization
X
determines
that a “fast” appeal is necessary, it must notify the
Medicare member as quickly as the member's health requires but no
later than 72 hours.
|
How
many “fast”
appeals
did the IRE
consider?Organization
X
receive?
|
The IRE considered 86 appeals from (XYZ Organization).
X
received
20
requests
for "fast” appeal from its Medicare members.
(lines
914
through 1316
on the attached report)
|
What
happened?
|
The IREWhen
a member requested a “fast”
review,
Organization
X
agreed with the Medicare member's appeal 19that
a “fast” review was needed 75%
of the time.
Organization
X
did
not agree to a “fast” review 25%
of
the time.
This means that in 19% of these cases, (XYZ
Organization) ended up paying for or providing all services
that these number
may include requests by members
asked for. who
the organization may not have believed were in danger or might
suffer serious harm.
The IRE
disagreed with the Medicare member's appeal 70% of the
time. This means that in 70% of these cases, (XYZ
Organization) ended up not paying for or providing all
services that these members asked for.
Medicare
members withdrew their request for independent review 9% of
the time.
By June 01,
2007, 2% of appeals were still waiting to be reviewed by
the IRE.
NOTE:
These percentages may not add to 100% because sometimes the IRE
dismisses an appeal.
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Page
53
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QualityIndependent
Review
of Care Grievance InformationAppeals
on Page 64
|
Information
on Independent Review
April
1, 2006 to March 31, 2007
INFORMATION ON QUALITY
OF CARE GRIEVANCES
April
1, 2006 to March 31, 2007
|
What
is a
qualityIndependent
Review
of care
grievance?an
appeal?
|
After
a member has sent an appeal to Organization
X,
if the organization continues to decide that it should not pay
for or provide all services that the member asked for,
Organization
X
must
send all of the information about the appeal to an independent
review entity (IRE) that contracts with Medicare, not with
Organization
X.
An
independent review provides an opportunity for a new, fresh look
at the appeal outside of the organization. A
grievance is a complaint that a Medicare member makes about the
way (XYZ Organization) provides care (other than
complaints about requests for service or payment). A grievance
about the quality of care is one kind of
grievance. For example, a member can file a grievance about the
quality of care when the member believes that the service the
member received was not timely or correct, when the member had
problems getting a service because of long waiting times or long
travel distances, or when the wrong kind of doctor or hospital
provided the service.
CMS’
IRE goes over all of the information from Organization
X
and
can consider any new information.
If
the IRE does not agree with Organization
X's
decision, Organization
X
must
provide or pay for the services that the Medicare member
requested.
There
may be several reasons why the IRE decides to agree with either
the Medicare member or Organization
X.
For example, the IRE may disagree with Organization
X
because
the IRE may have had more information about the appeal.
|
How many quality of care
grievances did (XYZ
Organization)
receive?
|
(XYZ Organization) received 20 grievances about the
quality of care. About less than 1 out of every 1,000
Medicare members filed a grievance about the quality of care they
received from (XYZ Organization) doctors and hospitals.
(lines 2 and
4 under “Quality of Care Grievance Data” on the
attached report)
|
Where can I get more
information?
|
If you are a member of (XYZ Organization), you have the
right to file an appeal or grievance.
You can
contact (XYZ Organization) at (###) ###-#### to resolve a
concern you may have or to get more information on how to file an
appeal or grievance. (Be sure to include a phone number for the
hearing impaired and your hours of operation.) You may also
refer to your Evidence of Coverage for a complete explanation of
your rights.
You also can
contact a group of independent doctors in STATE, called a
Quality Improvement Organization, at (###) ###-#### for more
information about quality of care grievances or to file a quality
of care grievance.
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Page 6
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Page
4
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Quality of Care Grievance
Information on Page 5
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Information
on Independent Review
April
1, 2006 to March 31, 2007
How
many appeals did the IRE consider?
|
The
IRE considered 86
appeals
from Organization
X.
(lines
9 through 13 on the attached report)
|
What
happened?
|
The
IRE agreed with the Medicare member's appeal 19%
of
the time. This means that in 19%
of
these cases, Organization
X
ended
up paying for or providing all services that these members asked
for.
The
IRE disagreed with the Medicare member's appeal 70%
of
the time. This means that in 70%
of these cases, Organization
X
ended
up not
paying for or providing all services that these members asked for.
Medicare
members withdrew their request for independent review 9%
of the time.
By
June 01, 2007, 2%
of appeals were still waiting to be reviewed by the IRE.
NOTE:
These percentages may not add to 100% because sometimes the IRE
dismisses an appeal.
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Page 5
|
Quality of Care Grievance
Information on Page 6
|
Information
on Quality of Care Grievances
April
1, 2006 to March 31, 2007
What
is a quality of care grievance?
|
A
grievance is a complaint that a Medicare member makes about the
way Organization
X provides care
(other than complaints about requests for service or payment). A
grievance
about the quality
of care is
one kind of grievance. For example, a member can file a grievance
about the quality of care when the member believes that the
service the member received was not timely or correct, when the
member had problems getting a service because of long waiting
times or long travel distances, or when the wrong kind of doctor
or hospital provided the service.
|
How
many quality of care grievances did Organization X
receive?
|
Organization
X received 20
grievances about the quality of care. About less
than 1 out of every 1,000
Medicare members filed a grievance about the quality of care they
received from Organization
X doctors and
hospitals.
(lines
2 and 4 under “Quality of Care Grievance Data” on the
attached report)
|
Where
can I get more information?
|
If
you are a member of Organization
X, you have the
right to file an appeal or grievance.
You
can contact Organization
X at (insert
phone number) to resolve a concern you may have or to get more
information on how to file an appeal or grievance. (Be sure to
include a phone number for the hearing impaired and your hours of
operation.) You may also refer to your Evidence of Coverage for a
complete explanation of your rights.
You
also can contact a group of independent doctors in STATE,
called a Quality Improvement Organization, at (insert QIO’s
phone number) for more information about quality of care
grievances or to file a quality of care grievance.
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Page
6
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OMB Approval No. 0938-0778
Form No. CMS-R-0282
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | CMS-R-0282 Sample Form |
Subject | Sample Form for MA Appeals and Grievances |
Author | CMS/CPC/MEAG/DAP |
File Modified | 0000-00-00 |
File Created | 2021-02-03 |