Collecting Appeals and Grievance Data

FORM INSTRUCTIONS CMS-R-0282
Medicare Advantage organizations are expected to disclose grievance and appeals data, upon
request, to individuals eligible to elect a Medicare Advantage organization. For purposes of this
section, by appeals data we mean all appeals filed with the Medicare Advantage organization
that are accepted for review, or withdrawn upon the enrollee’s request, but excludes appeals that
the organization forwards to CMS’ Independent Review Entity (IRE) for dismissal. Medicare
Advantage organizations should not send out a subset or partial list of the data, even if only a
subset of the data is requested. For example, if a beneficiary requests data on the number of
appeals received by the Medicare Advantage organization, then the Medicare Advantage
organization must send the beneficiary a complete report of both its appeal and grievance data
for the reporting period.
Medicare Advantage organizations must report to beneficiaries the number of appeal and
grievance requests per 1000 enrollees. The purpose of this calculation is to normalize reporting
among larger and smaller Medicare Advantage organizations for comparison purposes. Since
larger organizations would reasonably be expected to receive more appeals and grievances
relative to smaller organizations, simply reporting raw data could be misleading.
The rate is calculated by multiplying the total number of requests for an appeal or grievance by
1,000, and dividing that number by the average number of members enrolled during the data
collection period. The calculation does not require that the Medicare Advantage organization
have a minimal enrollment of 1000 members.
The following are examples of how the rates get normalized across small and large
organizations:
Example 1
Medicare Advantage organization average membership = 500
Number of appeals received during the data collection period = 4
4 multiplied by 1000/500 = 8
Number of Appeals per 1000 members = 8
Example 2
Medicare Advantage organization average membership = 5000
Number of appeals received during the data collection period = 40
40 multiplied by 1000/5000 = 8
Number of Appeals per 1000 members = 8
Reporting Unit for Appeal and Grievance Data Collection Requirements
The reporting unit for appeal and grievance data sent to beneficiaries is to be consistent with
(generally the same as) the reporting unit for the Health Plan Employer Data and Information Set
(HEDIS), the Medicare Consumer Assessment of Health Plans Study, and the Medicare Health
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Outcomes Survey. Therefore, Medicare Advantage organizations must make changes to the
reporting unit for appeals and grievances concurrently. However, CMS retains the flexibility to
grant special exceptions to the general reporting unit to allow for case-by-case exceptions for
good cause.
Data Collection and Reporting Periods
In order for Medicare Advantage organizations to report appeal and grievance data consistently,
data collection and reporting periods have been established.
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The data collection period is the timeframe in which the data were collected. Data
collection periods will be based on an ongoing 12 month period. By ongoing, we mean
that the prior 6 months of data are added to the next 6 months of data in order to come up
with a 12 month data collection period;
The reporting period refers to the timeframe during which organizations will be expected
to report the data. The reporting period begins 3 months after the data collection period
ends. Reporting periods are 6 months in duration; and
Organizations are expected to report out appeal and grievance data to Medicare
Advantage eligible individuals, upon request, beginning 3 months after the end of each
data collection period. For example, if the data collection period ended 9/30/05, the
organization would begin reporting data to the beneficiary 1/1/2013. The 3 month lag
between the end of the data collection period and the beginning of the report period
allows the Medicare Advantage organization to resolve appeals received during the data
collection period and ensure quality control over the data reported.

Below is a chart detailing the sample yearly collection and reporting cycles.
Sample Yearly Collection and Reporting Cycles
6 month Data
3 month
What kind of data?
Collection
Reconciliation
4/1/13 to 9/30/13
10/1/13 to 12/31/13
last 6 months
10/1/13 to 3/31/14
4/1/14 to 6/30/14
last 12 months
4/1/14 to 9/30/14
10/1/14 to 12/31/14
last 12 months, etc.

New Reporting Periods Start Every Six Months
Medicare Advantage organizations are expected to report out new data every 6 months. The new
data to be reported will include the two most recent data collection periods. For example, the
data collection period would begin each year starting on April 1 and ending on September 30,
thus the reporting period would run from January 1 through June 30. The next reporting period
begins July 1 and runs through December 31. This sample report includes appeal and grievance
data collected beginning April 1 through March 31 (or the two latest 6 month data collection
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periods). As an example, beneficiary requests for appeal and grievance data beginning January
1, 2014, through June 30, 2014, would be based on appeals received by the organization from
October 1, 2005, through September 30, 2013, and so on.
Maintaining Data
CMS expects Medicare Advantage organizations to maintain a health information system that
collects, analyzes and integrates the data necessary to implement disclosure requirements.
Appeal and Grievance Data Collection Requirements
The following describes the appeal and grievance data Medicare Advantage organizations are
expected to record and report. This format should be used by the organization in recording the
data internally and is the required format for reporting the information to beneficiaries. Reports
should be readable and understandable to the recipient of the information. The material also
should be typed in at least a 12-point font. Organizations should provide informational copies to
the appropriate Regional Office. If the Medicare Advantage organization intends to provide any
of its own materials or discussion to supplement CMS' standardized format, as with all member
materials, prior approval by the Regional Office is required.

Appeal Data

Line 1

Time Period(s) Covered: [Sample Reporting Period lasts from 1/1/14
through 6/30/14, which includes data collected from 10/1/05 through
9/30/13, and 7/1/14 through 12/31/14 which includes data collected from
4/1/13 through 3/31/14.]

Line 2.

Total Number of Requests for an Appeal Received by [Organization Name]:
[insert number here].
Instructions: This line includes all requests for reconsideration, including PreService (standard and expedited) and Claims (Payment) Appeals, but excludes
appeals that the organization forwards to CMS’ independent review entity for
dismissal.

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Line 3.

Average Number of Enrollees in [Organization Name]: [insert number here].
Instructions: To calculate the number of enrollees, count the number of
enrollees at the end of each month of the data collection period. Divide that total
by 12 (the total number of months in the data collection period).

Line 4.

Total Number of Appeal Requests per 1,000 enrollees: [insert number here]
Instructions: This number is calculated by multiplying the total number of
requests for an appeal (line 2) by 1,000 and dividing by the total number of
enrollees as of the last date of the data collection period (line 3).

Line 5.

Of the Appeal Requests Received by [Organization Name] between [sample 12
month period: 04/01/13 through 03/31/14], [Organization Name] completed
[insert number here].
Instructions: This number should be equal to or less than the number in line 2.
Organizations are reporting cases received in the period indicated in line 1, but
completed at the Medicare Advantage organization level within 60 days
following the last date in line 1. For example, a withdrawal would be reflected
in line 2 as a case received, but since a decision is not rendered for a withdrawn
case, a withdrawal would not be reflected in this line item.
A “completed” appeal means one that has been resolved by the Medicare
Advantage organization or has left the Medicare Advantage organization level.
If there were no withdrawals, we anticipate that the number of completed
appeals will be the same as the number of requests for reconsideration, provided
the Medicare Advantage organization has met its deadlines.
Therefore, the organization is accounting for all appeals that it has completed
within 60 days after the last date in line 1.
The 60 day timeframe is based on the maximum timeframe in
42 CFR 422.590(b), which allows a Medicare Advantage organization 60 days to
resolve a dispute involving a claim or request for payment either by deciding an
enrollee should receive payment or by forwarding the case to the IRE. Cases
involving requests for services have a shorter timeframe.
Of those cases:
NOTE: Partial denials should be recorded as not decided fully in favor of the
enrollee.

Line 6.

[Insert number here] or [insert percent here] of the appeals were decided
fully in favor of the enrollee.
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Line 7.

[Insert number here] or [insert percent here] of the appeals were not decided
fully in favor of the enrollee.

Line 8.

[Insert number here] or [insert percent here] of the appeals were withdrawn
by the enrollee.
[NOTE: When the decision is not fully in favor of the enrollee, or when the
decision is not completed within the required time, as specified in 42 CFR
422.590, the case is automatically sent to the IRE.]

Line 9.

For all appeals received by [Organization Name] between [sample 12 month
period: 04/01/13 through 03/31/14], [insert number here] cases were sent to
the IRE for review.
Instructions: This number should be the same as the number in line 7, provided
that organizations forwarded all case files to CMS’ IRE in a timely manner.
Of those cases:
[NOTE: Partial denials should be recorded as not decided fully in favor of the
enrollee.]

Line 10.

[Insert number here] or [insert percent here] of [Organization's Name]
cases reviewed by the IRE were decided fully in favor of the enrollee.

Line 11.

[Insert number here] or [insert percent here] of [Organization’s Name]
cases reviewed by the IRE were not decided fully in favor of the enrollee.

Line 12.

[Insert number here] or [insert percent here] were withdrawn by the
enrollee.

Line 13.

[Insert number here] or [insert percent here] are still awaiting a decision by
the IRE.
In certain situations, the Medicare Advantage organization is required to process
an appeal faster because delay in making a decision could cause serious harm to
enrollees. This is called an expedited appeal. In many cases, it is the Medicare
Advantage organization that decides whether or not to expedite the appeal.
Instructions: The following measurements are meant to reveal how often the
Medicare Advantage organization granted requests for the expedited processing
of an appeal. (Expedited organization determinations are not covered by this
measure.)

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Line 14.

Between [sample 12-month period: 04/01/13 through 03/31/14] [Organization
Name] received [insert number here] requests for expedited processing for
appeals.
Of those cases:

Line 15.

[Insert number here] or [insert percentage here] of the requests for
expedited processing of the appeal were granted.
Instructions: This line includes cases where the decision was to expedite.

Quality of Care Grievance Data
Line 1.

Time Period Covered: [Sample Reporting Period lasts from 1/1/14
through 6/30/14, which includes data collected from 10/1/05
through 9/30/13, and 7/1/14 through 12/31/14 which includes data
collected from 4/1/13 through 3/31/14].

Line 2.

Total number of Quality of Care Grievances Received by
[Organization's name: insert number here].
Instructions: This line should only include grievances that involve
quality of care complaints received during the data collection period.

Line 3.

Average Number of Enrollees in [Organization's name]: [insert
number here].
Instructions: To calculate the number of enrollees, count the number of
enrollees at the end of each month of the data collection period. Divide
that total by 12 (the total number of months in the data collection
period).

Line 4.

Total Number of Quality of Care Grievances received per 1,000
enrollees [insert number here].
Instructions: This number is calculated by multiplying the total
number of grievances (line 2) by 1,000 and dividing by the total
number of enrollees as of the last date of the reporting period (line 3).
Instructions: This line should only include grievances that involve
quality of care complaints received during the data collection period.

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In addition to reporting raw data to beneficiaries, Medicare Advantage organizations also must
explain what the numbers mean in a separate report. See the Sample Report (Appendix 2) for
standardized language.
Explaining Appeal and Quality of Care Grievance Data Reports
The standardized language included in Appendix 2 provides both contextual information and,
where possible, offers an explanation about what the data provided by a Medicare Advantage
organization might suggest to a beneficiary. By doing so, Medicare Advantage organizations
will help beneficiaries make a connection between the processing and disposition of appeals.
On page 4 of Appendix 2, the report provides background regarding independent reviews. For
example, one sentence states that an independent review provides an opportunity for a new, fresh
look at the appeal outside of the plan. Also, in an effort to explain why the IRE might disagree
with the Medicare Advantage organization , the report offers that the IRE may have had more
information about the appeal.
Medicare Advantage organizations will meet the disclosure requirements set forth in the
regulations at 42 CFR 422.111(c)(3) by utilizing the report found at Appendix 2.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0778. The time required to complete this information collection is estimated
to average 60 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attention: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Form CMS-R-0282 (Exp. XX/XX/20XX)

OMB Approval 0938-0778

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