CMS-R-0282 Data Form_2023_

{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.
What is a level 1 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 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.
What can happen with level 1 appeals?	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. Sometimes, a member may decide to withdraw their appeal. Because the plan dismisses a withdrawn appeal, they are not included in this report.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.

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.

Where can I get more information about appeals and grievances?

If you are a member of {plan name}, you have the right to file an appeal or grievance. 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.

{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

	Description	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Year Total
1	Level 1 appeals received
2	Level 1 appeals per 1,000 members
3	Favorable level 1 appeal decisions
4	Unfavorable level 1 appeal decisions

Grievances

	Description	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Year Total
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)