Crosswalk

EXHIBIT A
Medicare Advantage Appeals and Grievance Data Disclosure Requirements
(CMS-R-282; OMB 0938-0778)

CHANGE CROSSWALK
FORM
Title:
Sample Report
(Appendix 2)
Medicare Appeals and
Quality of Care
Grievances
April 1, 2016 to March
31, 2017
On all pages throughout
the form:
•

Use of the term
“Organization X”

•

Sample dates and
numbers.

•

Footers that included
language for what
pages specific
information can be
found (e.g., “Appeals
information beginning
on page 2”)

On all pages throughout
the form:

CHANGES TO FORM
Title:
{Medicare Advantage
Plan Name} Appeals
and Grievances Data
Report
January 1, {Insert year
of report data} to
December 31 {insert
year of report data}
On all pages throughout
the form:
•

Updated the term
“Organization X” to
“{plan name}”.

•

Replaced sample
information with curly
brackets “{ }” and
italicized instructions.

•

Footers were
removed.

To reduce plan burden,
the form was changed
from a sample report to a
template with parts in
curly brackets “{ }” with
italicized instructions for
plans to enter plan
specific information, such
as “plan name” or “year of
data report”.
The title and various
places throughout the
form has been revised to
reflect this change.
References to “Appendix
2” of Chapter 13 of the
Medicare Managed Care
Manual have been
removed, as this
guidance is no longer
applicable.
Footers were removed
because information is
easier to find due to the
form being reduced from
seven to three pages.

“Medicare member”
changed to “member”.

To more clearly
distinguish the members
being referenced in the
form are members of the
plan and not original
Medicare beneficiaries.

Removed references to
the term “quality of care

Grievances data in the
report will reflect both

“Medicare member”

On all pages throughout
the form:

EXPLANATION

FORM
Quality of care grievances

CHANGES TO FORM
grievances” and changed
to “grievances”.

EXPLANATION
grievances and quality of
care grievances.

On page 1, under
heading “What kind of
information is this?”

On page 1, under
heading “What kind of
information is this?”

When asked, the
government requires
Organization X to provide
reports that describe what
happened to formal
complaints that
Organization X received
from their Medicare
members. There are two
types of formal complaints:
Appeals and Grievances.

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}.

First paragraph removed
to reduce the
unnecessary and
repetitive language within
the form.

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
Organization X received
between April 1, 2016,
and March 31, 2017.
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

Added language in
second paragraph to
explain why this report
may be requested and
updated with curly
brackets “{ }” and
italicized instructions for
plans to insert plan name
and the year the data in
the report is from.
Last paragraph is
removed so individuals do
not misinterpret why
some plan’s data may be
different than others.

FORM
their concerns and agrees
to solutions. Alternatively,
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.

CHANGES TO FORM

EXPLANATION

Section titled:

Section titled:

“How big is Organization
X?”

“How many members
does {plan name} have?”

Throughout the form,
there is use of the term
“appeal” when referring to
a plan level
reconsideration.

Updated the term
“appeal” to “level 1
appeal” (when related to
a plan level
reconsideration).

To ensure universal
language throughout
various appeals related
guidance and
notices/forms issued by
CMS.

Under section titled:

Under section titled:

“What is an appeal?”

“What is a level 1
appeal?”

Added “level 1” and “to
the plan” to clarify this is a
level 1 plan 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.

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.
If a member cannot get
an item or service that the
member feels they need,
or if the organization has
denied payment of a
claim for a service the
member has already
received, the member can

Heading changed to be
more specific and clarify
the information being
provided is the number of
enrollees.

Removed the term
“complaint” and replaced
with “request” to clarify an
appeal is a request for a
review and not a
complaint/grievance.
Removed gender specific
pronouns.
Added “appeal to the
plan” to clarify level 1
appeals are plan level
appeals and requests
should be made to the
plan.
Added a sentence

FORM

CHANGES TO FORM
appeal to the plan.
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.

All of pages 3 through 5,
related to “Expedited or
“fast” appeals” and
“Information on
independent review” and
sections titled:
•

“How many appeals did
Organization X
receive?”

•

“How many appeals did
Organization X
review?”

•

“How many quality of
care grievances did
Organization X
receive?”

Sections were removed.

EXPLANATION
notifying individuals
where they can find
specific information
regarding number of
appeals and number of
appeals per 1,000
enrollees in the attached
report.

Pages 3 through 5
regarding “fast appeals”
and “appeals the IRE
considered” were
removed because these
data elements are not
necessarily based on plan
performance. The
decision to expedite an
appeal request is based
on medical necessity and
the enrollee’s health
condition, which is
specific to the enrollee
making the request.
Further, expedited
appeals are already
included in number of
total appeals received.
For independent review,
IRE (level 2) appeals data
was removed because
overturn data is not
indicative of plan
performance (i.e., the
decision was overturned
because the IRE received
different information, not
because the plan’s
decision was incorrect).
The additional sections
removed contained

FORM

Section titled:
“What happened?”
From the 174 appeals it
received from its
members:
Organization X decided to
pay for or to provide all
services that the member
asked for 41% of the
time.
Organization X decided
not to pay for or to
provide the services that
the member asked for
49% of the time.
Medicare members
withdrew their request
before Organization X
issued a decision 10% of
the time.

CHANGES TO FORM

EXPLANATION
specific plan data, and a
simple, easy to read chart
was added at the end of
the report so individuals
could quickly and easily
find data and to reduce
plan burden (adding data
in one place in the form
versus two places).

Changed to “What can
happen with level 1
appeals?”

Section title changed to
provide clarification on
which type of appeals.

Plans may decide to pay
for or to provide all
services that the member
asked for. These are
called favorable
decisions.

Information regarding
plan specific appeal data
is removed to reduce plan
burden and enrollee
confusion (entering and
looking for data in two
different places). All data
is found in a table on one
page of the report.

Sometimes, plans decide
not to pay for or to
provide the services that
the member asked for.
These are called
unfavorable decisions.
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

Language is added to
define and easily
understand the difference
between favorable and
unfavorable decisions.
Language added to
define a withdrawal and
explain why withdrawals
are not included in the
report.
A sentence was added to
help enrollees easily
identify where this
information can be found
on the report.

FORM

CHANGES TO FORM
can be found on line 4.

Section titled:

Replaced with:

“What is a quality of care
grievance”?

"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.

EXPLANATION
Data for “grievances” was
added so individuals have
data for all grievances.
Quality of care grievances
have been included in the
total number of
grievances.
A section has been
created to provide the
individual with a definition
of a grievance.

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.
Section titled:

Section titled:

“Where can I get more
information?”

“Where can I get more
information about appeals
and grievances?”

You can contact
Organization X at (insert
phone number) to resolve
a concern you may have
or to get more information

You can contact {plan
name} at {insert plan
phone number} to resolve
a concern you may have
or to get more information

Changed title to specify
contact information is for
information on appeals
and grievances.
Added sentence with
instructions in curly
brackets “{ }” to add TTY
number.
Changed “Quality

FORM
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.
Current form has no
report/table to insert data.

CHANGES TO FORM
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.

EXPLANATION
Improvement
Organization” to
“Beneficiary and Family
Centered Care-Quality
Improvement
Organization (QIO)” to
reflect recent change in
name of QIO.

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.
New page titled:
{Plan Name} Appeals
and Grievances Data
Report
January 1, {insert year
of report data} to
December 31, {insert
year of report data}
Page includes a place for
plans to insert average
number of enrollees in the
plan and italicized
instructions in curly
brackets, “{ }”for plans to
insert applicable data in
the table titled “Level 1
Appeals”. Table includes
cells to enter quarterly
and yearly data for:

Specific template for a
data table template was
added so individuals
requesting reports from
multiple plans have
reports in the same
format and all data can be
found in one place in the
report. This also
eliminates the need for
plans to create their own
report.

FORM

CHANGES TO FORM
• Level 1 appeals
received
• Level 1 appeals per
1,000 members
• Favorable level 1
appeal decisions
• Unfavorable level 1
appeal decisions
A second table titled
“Grievances” is included
and provides titled cells to
enter quarterly and yearly
data for:
• Grievances received
• Grievances per 1,000
members
This page also explains
which months each
quarter in the tables
represent:
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

EXPLANATION

FORM
Current form has No PRA
disclosure statement.

CHANGES TO FORM
Added PRA disclosure
statement:
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 C4-2605, Baltimore, Maryland
21244-1850.

EXPLANATION
Per PRA requirements.

INSTRUCTIONS
On all pages, the
following terms are used:
•
•

“Medicare Advantage
Organization”
“Member”

On page 1:

CHANGES TO
INSTRUCTIONS

EXPLANATION

•

Updated the term
“Medicare Advantage
Organization” to
“Plans”.

Change made to simplify
and reduce text within
instructions.

•

Changed “member” to
“enrollee”

On page 1:

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
excluding appeals that
the organization forwards
to CMS’ Independent
Review Entity (IRE) for
dismissal.

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).

On Page 1:

On Page 1, added a
heading between the first
and second paragraph
that states:

No heading identifying
how to calculate the
number of appeals and
grievances.

Changed to ensure
universal language
throughout various
appeals related guidance
and notices/forms issued
by CMS.

“Calculating Number of
Appeals and Grievances”

Added “i.e., beneficiaries”
to identify the types of
individuals that may
request a data report.
Sentence regarding what
data is included, was
removed. Plans no longer
forward cases to the IRE
for dismissal.

To clearly identify where
to find information on how
to calculate number of
appeals and grievances.

INSTRUCTIONS

CHANGES TO
INSTRUCTIONS

EXPLANATION

On page 1:

On page 1:

The following are
examples of how the
rates get normalized
across small and large
organizations:

See examples below:

On page 1: Section titled:

Section titled, “Reporting
Unit for Appeal and
Grievance Data
Collection Requirements”
has been removed.

Ensuring data is
consistent with HEDIS,
CAHPS and HOS is no
longer pertinent.

On page 2:

Added language to
indicate the data used in

Reporting Unit for
Appeal and Grievance
Data Collection
Requirements

Change made to simplify
and reduce text within
instructions.

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
Outcomes Survey.
Therefore, plans 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.
On page 2:

INSTRUCTIONS
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.
• The data collection
period is the timeframe in
which the data was
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 appeal
and grievance data to
Medicare Advantage

CHANGES TO
INSTRUCTIONS
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.
•

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:

January 1 – March 31
April 1 – June 30
July 1 – September 30
October 1 – December 31
•

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,

EXPLANATION
the report is the same as
data submitted to CMS
for the Part C reporting
requirements. Also, the
data collection and
reporting periods align
with Part C reporting
requirements. Data
collection periods are
outlined in the
instructions.
A chart in the form with
Sample Yearly Collection
and Reporting Cycles,
has been removed
because collection and
reporting periods have
changed.

INSTRUCTIONS
eligible individuals, upon
request, beginning 3
months after the end of
each data collection
period. For example, if
the data collection period
ended 9/30/15, the
organization would begin
reporting data to the
beneficiary 1/1/2016. 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.

CHANGES TO
INSTRUCTIONS
plan reported
grievance and appeals
data for 2018
submitted to CMS in
February 2019, would
be used April 1, 2019
through March 31,
2020 in reports
requested by
individuals.

EXPLANATION

Below is a chart detailing
the sample yearly
collection and reporting
cycles.
On pages 2 and 3,
sections with the heading:

These sections have
been removed.

Sections removed
because collection and
reporting periods have
changed.

On page 3:

On page 3:

Appeal and Grievance
Data Collection
Requirements

Appeal and Grievance
Data Report
Instructions

Title changed to more
appropriately describe
what is found in the
section (i.e., report
instructions).

“New Reporting Periods
Start Every Six Months”
And
“Maintaining Data”

INSTRUCTIONS
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.

No section in current form
instructions describing the
first section of the form.

CHANGES TO
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.
On page 2:
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.

On pages 6 and 7,
sections titled (and

Number of data elements
was reduced from

EXPLANATION

Added paragraph to
provide a brief description
of the beginning of the
form, as well as provide
instruction to plans for
inserting information into
curly brackets, “{ }”
throughout the form.

INSTRUCTIONS
instructions for each
section):
Appeal Data
Line 1
Time Period(s) Covered:
Line 2.
Total Number of
Requests for an Appeal
Received by
[Organization Name]:
[insert number here].
Line 3.
Average Number of
Enrollees in [Organization
Name]: [insert number
here].
Line 4.
Total Number of Appeal
Requests per 1,000
enrollees: [insert number
here]
Line 5.
Of the Appeal Requests
Received by
[Organization Name]
between [sample 12
month period: 04/01/16
through 03/31/17],
[Organization Name]
completed [insert number
here].
Line 6.

CHANGES TO
INSTRUCTIONS
nineteen to six. All
elements in form were
removed and replaced
with the following:
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.

EXPLANATION
New instructions for how
to insert information into
the last page of the form
with the data report and
table. Instructions include
how to calculate average
number of enrollees, total
appeals and grievances
per 1,000 enrollees, and
where the information in
this report can be found in
CMS Part C reporting
requirements.

INSTRUCTIONS
[Insert number here] or
[insert percent here] of
the appeals were decided
fully in favor of the
enrollee.
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.
Line 9.
For all appeals received
by [Organization Name]
between [sample 12
month period: 04/01/16
through 03/31/17], [insert
number here] cases were
sent to the IRE for review.
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

CHANGES TO
INSTRUCTIONS
This line includes all
requests for
reconsideration, including
pre- service (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

EXPLANATION

INSTRUCTIONS
[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.
Line 14.
Between [sample 12month period: 04/01/16
through 03/31/17]
[Organization Name]
received [insert number
here] requests for
expedited processing for
appeals.
Line 15.
[Insert number here] or
[insert percentage here]
of the requests for
expedited processing of
the appeal were granted.

CHANGES TO
INSTRUCTIONS
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.
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

EXPLANATION

INSTRUCTIONS

CHANGES TO
INSTRUCTIONS
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.

EXPLANATION

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.
On page 6, Sections
titled:
Quality of Care Grievance
Data

All language in this
section related to “quality
of care grievances” was
removed.

Data for “grievances” was
added and quality of care
grievances have been
included in the total
number of grievances;
these line items are no

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EXPLANATION
longer needed.

Line 1.
Time Period Covered:
[Sample Reporting Period
lasts from 1/1/17 through
6/30/17, which includes
data collected from
10/1/15 through 9/30/16,
and 7/1/17 through
12/31/17 which includes
data collected from 4/1/16
through 3/31/17].
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).

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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.
On page 7:
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

All language removed.

Information is no longer
relevant due to sample
report changing to a
template format.

INSTRUCTIONS
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.

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