Currentnetwork_healthPolicy n03517
Appeals and Grievance Resolution Policy for Medicare Advantage - Part D Plans
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Defines Network Health Insurance Corporation's procedures for handling member appeals, redeterminations, grievances, and related processes for Medicare Advantage Part D enrollees, including timelines, roles, and escalation to the Independent Review Entity (IRE). Affects NHIC Part D members, their representatives, treating providers, and internal NHIC staff.
Policy Summary
Payernetwork_health
PolicyAppeals and Grievance Resolution Policy for Medicare Advantage - Part D Plans
Policy CodePolicy n03517
Change TypeMinor revision — no material clinical or coverage changes
Effective DateNov 11, 2021
Last ReviewNov 11, 2022
Next Review DateNov 11, 2022
Key ActionProviders may request redeterminations or expedited redeterminations on behalf of members and may submit evidence orally or in writing; redetermination requests must be filed within 60 days unless good cause is shown.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
7 daysstandard redetermination decision timeframe
7d / 30deffectuation when NHIC reverses
72h / 30deffectuation after external reversal
60 daysmember filing deadline
24 hoursnotify IRE if timeline missed
Appeals, Redeterminations, Effectuation, and Grievances
inv-01: Appeals, redetermination, effectuation and grievance criteria
Covered when ALL of the following procedural, timeline, and notice requirements apply to standard and expedited redeterminations, effectuation when decisions are reversed, and grievance handling.
ALL of the following
ALL of the following
- NHIC must decide as expeditiously as the member's health requires but no later than 7 calendar days from receipt of the standard redetermination request; the day of receipt is day zero and the 7-day period starts the next day.
ALL of the following
- NHIC must make reasonable and diligent efforts to obtain necessary medical records and pertinent information within time limits, document attempts, and if unable to obtain records, decide based on available evidence.
ALL of the following
- Written redetermination/denial notice must be understandable and include: the specific reason for denial (considering member's condition, disabilities, language needs); a description of applicable Medicare/Part D coverage rules and any formulary criteria; information on the right to reconsideration including both standard and expedited processes; and the completed model Request for Reconsideration form sent with the notice.
ALL of the following
- If NHIC reverses, send an understandable approval notice explaining approval conditions (duration, limitations, rules for subsequent refills).
ALL of the following
ALL of the following
- Member, member's representative, or treating physician may request expedited redetermination when applying the standard timeframe could seriously jeopardize the enrollee's life, health, or ability to regain maximum function; requests for payment of benefits already provided are not eligible for expedited review.
ALL of the following
- If granted, NHIC must decide as expeditiously as the member's health requires but no later than 72 hours from receipt of the request; NHIC must request any necessary medical information within 24 hours of the initial expedited request and may make the determination based on information available within the 72-hour period.
ALL of the following
- If a physician or other prescriber requests or supports the request and indicates that applying the standard timeframe could jeopardize the enrollee, NHIC must grant the expedited request.
ALL of the following
- NHIC must transfer the request to the standard redetermination process, provide prompt oral notice meeting specified requirements, and mail a written notice within 3 calendar days explaining transfer, right to file expedited grievance, and instructions to resubmit with prescriber support.
ALL of the following
ALL of the following
- If NHIC reverses a redetermination of a request for benefits in favor of the member, NHIC must effectuate the benefit as expeditiously as the member's health requires but no later than 7 calendar days from receipt of the standard redetermination request.
ALL of the following
- If NHIC reverses a redetermination of a request for payment, NHIC must authorize payment within 7 calendar days and make payment no later than 30 calendar days from receipt of the redetermination request.
ALL of the following
- If an IRE or higher-level appeal reverses NHIC's determination for a request for benefits, NHIC must authorize or provide the disputed benefit within 72 hours of receiving notice of the reversal and inform the IRE that it has effectuated the decision.
- If an IRE or higher-level appeal reverses a request for payment, NHIC must authorize payment within 72 hours and make payment no later than 30 calendar days from receipt of notice reversing the coverage determination; NHIC must inform the IRE that it has effectuated the decision.
ALL of the following
- If NHIC upholds an at-risk determination on redetermination, the case must be auto-forwarded to the Independent Review Entity (IRE) for review and resolution.
- If the adjudication timeframe expires without a decision, NHIC must forward to the IRE per applicable procedures and notify the member as required.
ALL of the following
- Timelines to submit a reopening request: within 1 year from the date of the organization determination or reconsideration for any reason; within 4 years for good cause; or at any time for reliable evidence of fraud, clerical error, or to effectuate NCD decisions.
- Good cause for reopening includes new and material evidence not available at the time of determination or evidence showing an obvious error; change in CMS legal interpretation or policy is not a basis for reopening.
ALL of the following
- Complaints that include both appeals and grievances must be processed under the appropriate procedures for each issue; multiple issues in one complaint should be processed separately and simultaneously to the extent possible.
inv-02: Coverage and appeal processing criteria
Covered when ALL of the following procedures and timelines for effectuation, expedited processing, IRE decisions, reopening requests, and complaint handling apply.
ALL of the following
- Benefits: when NHIC reverses a redetermination for a request for benefits in favor of the member, NHIC must effectuate the benefit as expeditiously as the member's health requires but no later than 7 calendar days from receipt of the redetermination request.
- Payments: when NHIC reverses a redetermination for a request for payment, NHIC must authorize payment within 7 calendar days and remit payment no later than 30 calendar days from receipt of the redetermination request.
ALL of the following
- If IRE or a higher-level appeals body reverses NHIC for requests for benefits, NHIC must authorize or provide the disputed benefit within 72 hours of receiving notice of the reversal and inform the IRE that the decision was effectuated.
- If IRE or higher-level reverses a request for payment, NHIC must authorize payment within 72 hours and make payment no later than 30 calendar days from receipt of notice reversing the coverage determination; NHIC must inform the IRE that it effectuated the decision.
ALL of the following
- Eligibility: member, representative, or treating physician may request expedited redetermination when standard timeframes could seriously jeopardize life, health, or ability to regain maximum function; requests for payment of benefits already provided are ineligible.
- Operational procedures: NHIC must establish on-call staff and procedures for accepting and documenting oral or written expedited requests, including entering oral requests into tracking systems and keeping documentation in the case file.
- Decision and information timelines: NHIC must determine promptly whether to expedite, request necessary medical information within 24 hours of an expedited request, and, if granted, render a decision no later than 72 hours from receipt of the request based on available information.
- Automatic grant when prescriber-supported: if a prescriber requests or supports the expedited request indicating jeopardy, NHIC must grant the expedited request.
- When expedited request denied: transfer to standard redetermination, provide prompt oral notice and mail written notice within 3 calendar days explaining transfer, rights to file an expedited grievance, resubmission instructions, and grievance process timelines.
ALL of the following
- When a complaint contains both appeals and grievances, process each issue under the appropriate procedure; if multiple issues are raised, process each separately and concurrently to the extent possible.
ALL of the following
- Timelines: reopening requests must be submitted within 1 year from the date of the organization determination or reconsideration for any reason; within 4 years for good cause as defined in applicable guidance; or at any time for reliable evidence of fraud, clerical error, or to effectuate NCD decisions.
- Good cause definition: new and material evidence not previously available or evidence showing an obvious error constitute good cause; a change in CMS legal interpretation or policy is not a basis for reopening.
- Reopening workflow when IRE overturns and NHIC disagrees: Appeals & Grievance department prepares a draft Reopening Request with supporting evidence, routes for departmental input, obtains final approval from chief medical officer and general counsel, and sends final Reopening Request to the IRE within required timelines, following up as needed.
ALL of the following
- NHIC will comply with CMS regulations governing effectuation, appeals, and reopenings and will incorporate procedures to comply with applicable CMS, NCQA, and other Part D regulations as amended.
Regulatory References and Decision Thresholds
Regulatory referencesmixed
| 42 CFR Part 423, Subpart M | Code of Federal Regulations Title 42, Part 423, Subpart M |
| CMS Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Manual | CMS chapter, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Manual |
Expedited decision threshold
Expedited decision standardDecision must be made as expeditiously as the member's health requires; if approved, NHIC must decide and notify no later than 72 hours after receiving the expedited redetermination request.
Medical information request timingNHIC must request any necessary medical information within 24 hours of the initial expedited redetermination request.
If expedited deniedIf NHIC denies the request to expedite, it must transfer the request to the standard redetermination process and provide prompt oral notice followed by written notice within 3 calendar days; standard redetermination time frame is 7 calendar days.
Ineligible for expedited reviewRequests for payment of a benefit already provided to a member are not eligible for expedited redetermination.
Provider-Initiated Appeals, Evidence, and Effectuation Responsibilities
Prior Authorization
Provider-initiated redeterminations and evidence submission
Providers (treating physicians or their staff) may request redeterminations or expedited redeterminations on behalf of members and may submit supporting evidence orally or in writing. Redetermination requests must be filed within 60 calendar days from the date printed or written on the denial notice unless good cause is shown; NHIC may accept late requests if a written good-cause explanation is provided. For representatives, a request is not valid until supported by an executed appointment-of-representative form or statement, and NHIC must inform the enrollee and purported representative in writing if documentation is missing.
- Expedited redetermination may be requested by a member, member’s representative, or prescribing physician when applying the standard timeframe could jeopardize the member’s life, health, or ability to regain maximum function; requests for payment of benefits already provided are not eligible for expedited review.
- Redetermination filing deadline: within 60 calendar days of the denial notice; provider/representative may request a good-cause extension in writing explaining why the request was late.
- Representative requests require an executed appointment-of-representative form or statement before NHIC will consider the redetermination; NHIC must notify the enrollee and purported representative in writing if the documentation is not provided.
Prior Authorization
Effectuation timelines when determinations are reversed
When NHIC reverses a coverage determination in favor of a member, NHIC must effectuate benefits or at‑risk changes as expeditiously as the member’s health requires but no later than seven (7) calendar days from receipt of the redetermination request; if the reversal is for a request for payment, NHIC must authorize payment within seven (7) calendar days and remit payment no later than thirty (30) calendar days. If an IRE or higher-level appeal reverses NHIC, NHIC must authorize or provide the disputed benefit within seventy‑two (72) hours of receiving the reversal notice and inform the IRE that it has effectuated the decision.
- Benefit authorizations or implementation for NHIC reversals: effectuate no later than 7 calendar days (sooner if the member’s health requires).
- Payment reversals by NHIC: authorize within 7 calendar days and make payment no later than 30 calendar days from receipt of the redetermination request.
- Reversals by IRE or higher-level appeal: authorize/provide the benefit within 72 hours of notice and notify the IRE that NHIC has effectuated the decision.
Key Terms
Key defined terms
Adverse DeterminationA decision by NHIC or its delegated entities to deny, reduce, or discontinue a requested service or payment (including discontinuation of previously authorized treatment).
AppealProcedures for review of adverse coverage determinations (includes redetermination by NHIC, reconsideration by the IRE, ALJ hearings, MAC review, and judicial review).
Expedited RedeterminationAn accelerated redetermination requested by a member, representative, or treating provider when applying the standard timeframe could jeopardize the enrollee's life, health, or ability to regain maximum function.
GrievanceA complaint or dispute other than a coverage determination, at-risk determination, or LEP determination, relating to dissatisfaction with plan operations or services; grievances are processed separately from appeals.
Independent Review Entity (IRE)
Independent Review Entity (IRE)An independent entity contracted by CMS to review Part D plan sponsor denials of coverage determinations; currently C2C Solutions, Inc.
Role in processPer policy, IRE conducts reconsiderations and higher-level reviews and may overturn NHIC determinations, triggering expedited effectuation timelines for NHIC.
Medical Director
Medical Director roleA licensed physician responsible for ensuring the clinical accuracy of all coverage determinations and redeterminations involving medical necessity (per 42 CFR 423.562(a)(5)).
ScopeOversees clinical aspects of standard and expedited appeals and grievances and ensures decisions reflect medical necessity standards.
Appeals vs Grievances
AppealsUsed for complaints or disputes involving coverage determinations (denials, reductions, terminations) and follow the redetermination/reconsideration/appeal process.
GrievancesUsed for non-coverage complaints (e.g., dissatisfaction with plan operations or benefit design); grievances are separate from appeals and decisions under grievance procedures are not appealable.
Misclassification handlingIf a grievance is misclassified as an appeal and the IRE determines misclassification, the appeal is dismissed and returned to NHIC to be processed as a grievance; NHIC must notify the member in writing of the reclassification.
Expedited redetermination
DefinitionAn expedited redetermination is an accelerated review requested when applying the standard timeframe could seriously jeopardize the enrollee's life, health, or ability to regain maximum function.
Who may requestMember, member representative, or treating physician/prescriber may request an expedited redetermination; physician support (oral or written) requires NHIC to grant the request if it indicates jeopardy.
Trigger conditionsStandard timeframe could 'seriously jeopardize' life, health, or ability to regain maximum function; requests for payment of benefits already provided are ineligible.
Policy Summary
Payernetwork_health
PolicyAppeals and Grievance Resolution Policy for Medicare Advantage - Part D Plans
Policy CodePolicy n03517
Change TypeMinor revision — no material clinical or coverage changes
Effective DateNov 11, 2021
Last ReviewNov 11, 2022
Next Review DateNov 11, 2022
Key ActionProviders may request redeterminations or expedited redeterminations on behalf of members and may submit evidence orally or in writing; redetermination requests must be filed within 60 days unless good cause is shown.
SourceLink
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