Medicare Parts C and D Universal Audit Guide

Attachment II-A
Grievances

Beneficiary
Name

Beneficiary
HICN

Att II-A Grievances, 1 of 1

CMS
Contract
ID

CMS Plan
ID

Date
Grievance/C
omplaint
was
Received
Date

Time
Grievance/C
omplaint
was
Received

How was the
grievance/complaint
received (e.g. written
letter, call to Customer
Services, etc.)

Category of the grievance/complaint (at a
minimum, categories must include each of
the following: Enrollment/Disenrollment;
Plan Benefits; Pharmacy Access; Customer
Service; Coverage
Determinations/Exceptions Process; Appeals Description of the issue (ensure text field is formatted so text
Process; Other
wraps and the entire field is readable)

Y/N Flag to indicate if
the
grievance/complaint
was processed under
the expedited
timeframe

Date oral
notification provided
to beneficiary (if no
oral notification,
please indicate N/A)

Time oral notification
provided to
beneficiary (if no
oral notification,
please indicate N/A)

Date written
notification of
resolution
provided to
beneficiary

Time written
notification of
resolution
provided to
beneficiary

Was request properly
identified as a grievance?
If not, was it quickly and
appropriately forwarded
Description of the resolution (ensure text field is formatted so text wraps and processed (as a CD or
and the entire field is readable)
appeal)?

Was request processed timely
and was enrollee appropriately Did plan take
notified within the required
appropriate action as a
timeframe?
result of the grievance? Pass/Fail

Comments

Condition

Criteria

Cause

Effect