Chapter 13 - Grievances

Question 1

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written grievance procedure information to enrollees or their representatives at initial enrollment

Answer 1

The Medicare health plan must provide all members with written grievance procedures upon initial enrollment, involuntary disenrollment (i.e., initiated by the Medicare health plan), annually, and upon request.
(13-10.2.0, 13-20.4.0)

Question 2

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written grievance procedure information to enrollees or their representatives upon involuntary disenrollment

Answer 2

The Medicare health plan must provide all members with written grievance procedures upon initial enrollment, involuntary disenrollment (i.e., initiated by the Medicare health plan), annually, and upon request.
(13-10.2.0, 13-20.4.0)

Question 3

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written grievance procedure information to enrollees or their representatives upon enrollee request

Answer 3

The Medicare health plan must provide all members with written grievance procedures upon initial enrollment, involuntary disenrollment (i.e., initiated by the Medicare health plan), annually, and upon request.
(13-10.2.0, 13-20.4.0)

Question 4

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written grievance procedure information to enrollees or their representatives annually

Answer 4

The Medicare health plan must provide all members with written grievance procedures upon initial enrollment, involuntary disenrollment (i.e., initiated by the Medicare health plan), annually, and upon request.
(13-10.2.0, 13-20.4.0)

Question 5

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Representatives received all grievance related notices and correspondence

Answer 5

All notices or other correspondence intended for the enrollee must be sent to the enrollee’s representative instead of to the enrollee
(13-10.3.1)

Question 6

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE included a description of the enrollee’s right to file a grievance with the QIO and the contact information for the appropriate QIO to which the enrollee may submit his or her quality of care grievance for all quality of care grievance responses.

Answer 6

All grievances regarding quality of care, regardless of whether they are filed orally or in writing must be responded to in writing. When the Medicare health plan responds to an enrollee’s grievance in writing, it must include a description of the enrollee’s right to file the grievance with the QIO and contact information for the appropriate QIO to which the enrollee may submit his or her quality of care grievance. (13-20.2.0)

Question 7

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification with resolution to all concerned parties no later than 30 calendar days from the date the grievance was filed

Answer 7

Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
(13-20.2.0)

Question 8

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification to all concerned parties regarding an organizations plan to take up to a 14 calendar day extension on a grievance case

Answer 8

Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
(13-20.2.0)

Question 9

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification to all concerned parties for expedited greivances no later than 72 hours from the time the initial grievances was filed.

Answer 9

• Ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 calendar days after the event;
• Ability to respond within 24 hours to an enrollee’s expedited grievance whenever:
• A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
• A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration;
• Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
• Prompt, appropriate action, including a full investigation of the grievance as expeditiously as the enrollee’s case requires, based on the enrollee’s health status, but no later than 30 calendar days from the date the oral or written request is received, unless extended as permitted under 42 CFR 422.564(e)(2);
• Timely transmission of grievances to appropriate decision-making levels in the organization;
• Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
• Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
• Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee; and
• Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, Medicare health plans must disclose grievance data to Medicare beneficiaries upon request. Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.2.0)

Question 10

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification to inform an enrollee that a complaint was misclassified

Answer 10

Medicare health plan must notify the enrollee in writing that the complaint was misclassified and will be handled through the Medicare health plan grievance process. The time frame for processing the complaint begins on the date the complaint is received by the Medicare health plan, as opposed to the date the Medicare health plan discovers its error. (13-20.3.1)

Question 11

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification to inform an enrollee of their right to file an expedited grievance upon denial of the enrollee’s request for an expedited appeal or a request for an expedited organization determination.

Answer 11

Medicare health plans are also required to provide all members with written notice about their right to file an expedited grievance upon denial of the enrollee’s request for an expedited appeal, a request for an expedited organization determination, or whenever the Medicare health plan decides to take an extension on a request for an organization determination or appeal.
(13-20.4.0)

Question 12

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE sent written notification to inform an enrollee of their right to file an expedited grievance whenever the Medicare health plan decides to take an extension on a request for an organization determination or appeal.

Answer 12

Medicare health plans are also required to provide all members with written notice about their right to file an expedited grievance upon denial of the enrollee’s request for an expedited appeal, a request for an expedited organization determination, or whenever the Medicare health plan decides to take an extension on a request for an organization determination or appeal.
(13-20.4.0)

Question 13

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Quality of Care grievance data is readily available for request by the enrollee or representative

Answer 13

Grievance quality care data is not readily available to members
(13-10.3.1)

Question 14

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Data transfer of member information to Quality Improvement Organizations is not conducted timely or accurately

Answer 14

Member information is not readily available to file a quality of care grievance with Quality Improvement Organizations
(13-10.3.1)

Question 15

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Authorization of a representative information was communicated to enrollees

Answer 15

It is HNE responsibility to inform the enrollee of form and authorization obligations and requirements. Grievances submitted without a representative form or with a defective representative form.
(13-10.4.1)

Question 16

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Form CMS-1696 Appointment of Representative or equivalent includes language and fields that conform to regulatory requirements

Answer 16

Form CMS-1696 Appointment of Representative or equivalent (if applicable) - valid for one year.
(13-10.4.1)

Question 17

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Written grievance notification includes how and where to file a grievance and the differences between appeals and grievances and appeals

Answer 17

Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
(13-20.3.0)
Any time a written grievance notification is required, Medicare health plans must include at least the following information:
• How and where to file a grievance; and
• The differences between appeals and grievances.
(13-20.4.0)

Question 18

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE utilizes accurate model notices, or regional office approved variation of the model notice to notify enrollees of their right to file an expedited grievance

Answer 18

Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
(13-20.3.0)

Question 19

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE documented efforts to obtain representative forms

Answer 19

HNE must make and document reasonable efforts to secure the necessary documentation
- Request for reprehensive form
(13-10.4.1)

Question 20

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE documented reasons for any organization plan grievance extension explaining how the extension is in the best interest of the enrollee

Answer 20

Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee;
(13-20.3.0)

Question 21

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE logs or captures enrollee grievances in a centralized location that is readily accessible

Answer 21

Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.2.0)

Question 22

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

Representative form CMS-1696 Appointment of Representative or equivalent is received and complete

Answer 22

-Form CMS-1696 Appointment of Representative or equivalent (if applicable)
• Includes the name, address, and telephone number of enrollee;
• Includes the enrollee’s HICN [or Medicare Identifier (ID) Number];
• Includes the name, address, and telephone number of the individual being appointed;
• Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
• Is signed and dated by the enrollee making the appointment; and
• Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment.
(13-10.4.1)

Question 23

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE identifies complaints correctly as grievance, organization determination, or appeal

Answer 23

One complaint letter may contain a grieveable issue and an appealable issue. If an enrollee addresses two or more issues in one complaint, then each issue should be processed separately and simultaneously (to the extent possible) under the proper procedure.
(13-20.1.0)
Grievance procedures are separate and distinct from organization determination and appeal procedures.
(13-20.2.0)

Question 24

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE resolved all grievances within the required time frame no later than 30 calendar days from the date the grievance was filed

Answer 24

Complaints that are grievances must be resolved no later than 30 calendar days after the date the organization receives the oral or written grievance.
Grievances filed orally, may be responded to orally unless the enrollee requests a written response or the grievance concerns quality of care. Grievances filed in writing must be responded to in writing.
(13-20.2.0)

Question 25

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE resolved all extended grievances within the required time frame no later than 44 calendar days from the date the grievance was filed

Answer 25

• Ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 calendar days after the event;
• Ability to respond within 24 hours to an enrollee’s expedited grievance whenever:
• A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
• A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration;
• Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
• Prompt, appropriate action, including a full investigation of the grievance as expeditiously as the enrollee’s case requires, based on the enrollee’s health status, but no later than 30 calendar days from the date the oral or written request is received, unless extended as permitted under 42 CFR 422.564(e)(2);
• Timely transmission of grievances to appropriate decision-making levels in the organization;
• Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
• Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
• Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee; and
• Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, Medicare health plans must disclose grievance data to Medicare beneficiaries upon request. Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.3.0)

Question 26

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE accepted all information and evidence concerning the grievance no later than 60 calendar days after the event

Answer 26

• Ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 calendar days after the event;
• Ability to respond within 24 hours to an enrollee’s expedited grievance whenever:
• A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
• A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration;
• Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
• Prompt, appropriate action, including a full investigation of the grievance as expeditiously as the enrollee’s case requires, based on the enrollee’s health status, but no later than 30 calendar days from the date the oral or written request is received, unless extended as permitted under 42 CFR 422.564(e)(2);
• Timely transmission of grievances to appropriate decision-making levels in the organization;
• Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
• Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
• Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee; and
• Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, Medicare health plans must disclose grievance data to Medicare beneficiaries upon request. Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.3,0)

Question 27

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE resolved all expedited grievances within the required time frame no later than 72 hours from the date the grievance was filed

Answer 27

• Ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 calendar days after the event;
• Ability to respond within 24 hours to an enrollee’s expedited grievance whenever:
• A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
• A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration;
• Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
• Prompt, appropriate action, including a full investigation of the grievance as expeditiously as the enrollee’s case requires, based on the enrollee’s health status, but no later than 30 calendar days from the date the oral or written request is received, unless extended as permitted under 42 CFR 422.564(e)(2);
• Timely transmission of grievances to appropriate decision-making levels in the organization;
• Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
• Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
• Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee; and
• Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, Medicare health plans must disclose grievance data to Medicare beneficiaries upon request. Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.3.0)

Question 28

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE grievance policies and procedures include required language, are reviewed and updated annually

Answer 28

• Ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 calendar days after the event;
• Ability to respond within 24 hours to an enrollee’s expedited grievance whenever:
• A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
• A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration;
• Use the model notice, or regional office approved variation of the model notice, to notify enrollees of their right to file an expedited grievance (see Appendix 6);
• Prompt, appropriate action, including a full investigation of the grievance as expeditiously as the enrollee’s case requires, based on the enrollee’s health status, but no later than 30 calendar days from the date the oral or written request is received, unless extended as permitted under 42 CFR 422.564(e)(2);
• Timely transmission of grievances to appropriate decision-making levels in the organization;
• Notification of all concerned parties upon completion of the investigation, as expeditiously as the enrollee’s case requires based on the enrollee’s health status, but not later than 30 calendar days from the date the grievance is filed with the health plan;
• Prompt notification to the enrollee or their representative regarding an organization’s plan to take up to a 14 calendar day extension on a grievance case;
• Documentation of the need for any extension taken (other than one requested by the enrollee) that explains how the extension is in the best interest of the enrollee; and
• Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, Medicare health plans must disclose grievance data to Medicare beneficiaries upon request. Medicare health plans must be able to log or capture enrollees’ grievances in a centralized location that is readily accessible.
(13-20.3.0)

Question 29

Written information to enrollees, their representatives, or non-contract providers was not communicated timely

HNE procedures are in place to use when the enrollee is incapable of receiving or incompetent to receive the notice, and the Medicare health plan cannot obtain the signature of the enrollee’s representative through direct personal contact

Answer 29

HNE must notify changes in coverage be made to the enrollee or representative of the enrollee.
Medicare Health plans are required to develop procedures to use when the enrollee is incapable of receiving or incompetent to receive the notice, and the Medicare health plan cannot obtain the signature of the enrollee’s representative through direct personal contact.
(13-10.4.3)