Reporting Appeals and Grievance Data

{Medicare Advantage Plan Name} Appeals and Grievances Data Report
January 1, {insert year of report data} to December 31, {insert year of report data}

What kind of
information is
this?

Medicare Advantage plan members have the right to file an appeal or
grievance with their plan. Individuals eligible to enroll in a Medicare
Advantage plan have the right to request information about the number of
appeals and grievances a plan receives. The next few pages contain
information about the appeals and grievances that {plan name} received in
{insert year of report data}.

How many
members does
{plan name}
have?

{Plan name} has about {insert average number of enrollees} members.

A level 1 appeal is a formal request for {plan name} to review {plan
name}'s decision not to pay for, not to provide, or to stop an item or
service that a member believes they need.

What is a level 1
appeal?

If a member cannot get an item or service that the member feels they need,
or if the plan has denied payment of a claim for a service the member has
already received, the member can appeal to the plan. For example, a
member might appeal our decision to stop physical therapy, to deny a visit
to a specialist, or to deny payment of a claim.
The number of level 1 appeals {plan name} had in {insert year of report
data} can be found on line 1 of the attached report. The number of level 1
appeals received per 1,000 members can be found on line 2.
Plans may decide to pay for or to provide all services that the member
asked for. These are called favorable decisions.
Sometimes, plans decide not to pay for or to provide the services that the
member asked for. These are called unfavorable decisions.

What can
happen with
level 1 appeals?

Sometimes a member may decide to withdraw their appeal. Because the
plan doesn’t do anything with a withdrawn appeal, they are not included in
this report.
The number of favorable level 1 appeal decisions {plan name} made can
be found on line 3 of the attached report. Unfavorable decisions can be
found on line 4.

Form CMS-R-0282

OMB Approval 0938-0778 (Expires: TBD)

What is a
grievance?

A grievance is a complaint that a member makes about {plan name}. For
example, a member can file a grievance when they are unhappy because
they believe their plan gives them too much or too little information, there
are long wait times when calling the plan, a doctor’s office waiting room
is too cold, or they have to travel long distances to get to their doctor.
The number of grievances {plan name} had in {insert year of report data}
can be found on line 5 of the attached report. The number of grievances
received per 1,000 members can be found on line 6.
If you are a member of {plan name}, you have the right to file an appeal or
grievance.

Where can I get
more information
about appeals and
grievances?

You can contact {plan name} at {insert plan phone number} to resolve a
concern you may have or to get more information on how to file an appeal
or grievance. TTY users can call {insert TTY phone number}. You may
also refer to your Evidence of Coverage for a complete explanation of your
rights.
You also can contact the Beneficiary and Family Centered Care-Quality
Improvement Organization (QIO) at {insert QIO’s phone number} for
more information about quality of care grievances or to file a quality of
care grievance.

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)

{Plan Name} Appeals and Grievances Data Report
January 1, {insert year of report data} to December 31, {insert year of report data}
Average Number of Members in {insert year of report data}: {insert average number of enrollees}

{Enter applicable appeals and grievances data in designated columns listed below}
Level 1 Appeals
Quarter
1

Description
1
2
3
4

Quarter
2

Quarter
3

Quarter
4

Year
Total

Quarter
2

Quarter
3

Quarter
4

Year
Total

Level 1 appeals received
Level 1 appeals per 1,000 members
Favorable level 1 appeal decisions
Unfavorable level 1 appeal decisions
Grievances
Quarter
1

Description
5 Grievances received
6 Grievances per 1,000 members

Quarter 1: January 1 – March 31
Quarter 2: April 1 – June 30
Quarter 3: July 1 – September 30
Quarter 4: October 1 – December 31
Year Total: January 1 - December 31

Form CMS-R-0282

OMB Approval 0938-0778 (Expires: TBD)