What’s happening: The Centers for Medicare & Medicaid Services (CMS) has implemented a new process allowing providers to submit questions and complaints related to Medicare Advantage (MA) plan appeals or claims payment issues.
What else to know: CHA welcomes these first steps in establishing greater CMS oversight for MA plans. The MA final rule, which took effect on Jan. 1, codified important new policies and expectations for MA plans, directed toward greater alignment between traditional Medicare and MA.
The complaint form is a cover sheet that must be submitted to CMS in a password-protected file along with requested documentation to a newly established dedicated email address box, as noted on the attached instructions and form. While CMS notes that they will not determine medical necessity or payment amounts, the agency will use the submitted information to identify trends for further investigation and action.
CMS also encourages hospitals and health systems to submit complaints about plan use of inappropriate utilization management criteria, prior authorization, or review practices to deny or downgrade coverage that the provider believes do not comply with CMS requirements to the following email address: part_c_part_d_audit@cms.hhs.gov.
