Collecting Appeals and Grievance Data

FORM INSTRUCTIONS CMS-R-0282
Medicare Advantage plans are expected to disclose grievance and appeals data, upon request,
to individuals eligible to elect a Medicare Advantage plan (i.e., beneficiaries). Plans 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 plan, then
the plan must send the beneficiary a complete report of both its appeal and grievance data for
the reporting period.
Calculating Number of Appeals and Grievances
Plans must report the number of appeal and grievance requests per 1,000 enrollees. The
purpose of this calculation is to normalize reporting among larger and smaller plans for
comparison purposes. Since larger plans would reasonably be expected to receive more
appeals and grievances relative to smaller plans, 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 enrollees enrolled during the data
collection period. The calculation does not require that the plan have a minimal enrollment of
1000 enrollees. See examples below:
Example 1
Medicare Advantage plan average enrollment = 500
Number of appeals received during the data collection period = 4
4 x 1,000/500 = 8
Number of Appeals per 1,000 enrollees = 8
Example 2
Medicare Advantage plan average enrollment = 5,000
Number of appeals received during the data collection period = 40
40 x 1,000/5,000 = 8
Number of Appeals per 1,000 enrollees = 8

Data Collection and Reporting Periods
In order for plans to report appeal and grievance data consistently, data collection and reporting
periods are aligned with CMS Part C reporting requirements. Plans may use the data reported to
CMS for data reports requested by individuals.
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The data collection period is the timeframe in which the data was collected. Data
collection periods will be quarterly and the same as CMS Part C reporting requirements
report period(s). Data collection periods are as follows:

Form CMS-R-0282

OMB Approval 0938-0778 (Expires: TBD)

January 1 – March 31
April 1 – June 30
July 1 – September 30
October 1 – December 31
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The reporting period refers to the timeframe during which plans report the data to
beneficiaries. The reporting period is from April 1 through March 31 of the following
year. For example, plan reported grievance and appeals data for 2018 submitted the
first and last Monday (respectively) of February 2019, would be used April 1, 2019
through March 31, 2020 in reports requested by individuals.

Appeal and Grievance Data Report Instructions
The following are instructions for each section and line item of the appeals and
grievances data reports for Form CMS-R-0282. Plans will meet the disclosure
requirements set forth in the regulations at 42 CFR 422.111(c)(3) using this form. This
format should be used by the plan 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. Plans should provide informational
copies to the appropriate regional office. If the plan intends to provide any of its own
materials or discussion to supplement CMS' standardized format, as with all enrollee
materials, prior approval by the regional office is required.

Explanation of Data Report
In addition to reporting raw data to beneficiaries, this form provides an explanation to
beneficiaries of what the numbers mean. This explanation of the data report includes
information about the report itself and defines level 1 appeals and grievances. Throughout the
form, text should be inserted into the curly brackets “{ }”, as explained.

Form CMS-R-0282

OMB Approval 0938-0778 (Expires: TBD)

Data Form

Average Number of
Enrollees

Insert the average number of enrollees.
To calculate the number of enrollees, count the number of
enrollees at the end of each month of the data report period.
Divide that total by 12 (the total number of months in the data
report period).

Line 1:
Total Number of
Level 1 Appeals
Received

Insert the number of level 1 appeals received in each quarter. This would
be organization determinations and reconsiderations data element
subsection #3A in reporting requirements.
Add the number of level 1 appeals for each quarter and put the total in the
“Year Total” column.
This line includes all requests for reconsideration, including preservice (standard and expedited) and claims (payment) appeals.

Line 2:
Total Number of
Level 1 Appeal
Received per 1,000
Enrollees

Insert the number of level 1 appeals received per 1,000 enrollees each
quarter.
This number is calculated by multiplying the total number of requests
for a level 1 appeal (line 1) by 1,000 and dividing by the average
number of enrollees for each quarterly column.
Add the number of level 1 appeals per enrollee for each quarter and put
the total in the “Year Total” column.

Line 3:
Favorable Level 1
Appeal Decisions

Insert the number of level 1 appeals that were decided as fully
favorable to the enrollee each quarter. This would be the total number
of organization determinations and reconsiderations data element
subsections #4A through #4D in reporting requirements.
Add the number of favorable level 1 appeals for each quarter and put the
total in the “Year Total” column.
NOTE: Partially favorable decisions should be recorded as
unfavorable decisions in line 4.

Form CMS-R-0282

OMB Approval 0938-0778 (Expires: TBD)

Line 4:
Unfavorable Level
1 Appeal Decisions

Insert the number of level 1 appeals that were unfavorable to the
enrollee each quarter. This would be the total number of
organization determinations and reconsiderations data element
subsections #4E through #4L in reporting requirements.
Add the number of unfavorable level 1 appeals for each quarter and put
the total in the “Year Total” column.

Line 5:
Number of
Grievances
Received

Insert the total number of grievances received each quarter. This would
be grievances data element A in reporting requirements.
Add the number of favorable level 1 appeals for each quarter and put the
total in the “Year Total” column.

Line 6:
Grievances
Received per 1,000
Enrollees

Insert the number of grievances received per 1,000 enrollees for each
quarter.
This number is calculated by multiplying the total number of
grievances (line 5) by 1,000 and dividing by the average number of
enrollees in each quarterly column.
Add the number of grievances per enrollee for each quarter and put the
total in the “Year Total” column.

PRA Disclosure Statement: 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

OMB Approval 0938-0778 (Expires: TBD)