CMS issued a new form and process for providers seeking assistance from CMS to resolve claims issues with Medicare Advantage (MA) plans. The new process will be centralized, rather than handled by CMS’ regional offices as in the previous process. CMS indicates that it will look for patterns among submitted complaints. The increased scrutiny is intended to encourage MA plans to address issues in a timely manner.
CMS has made the new form available through the American Hospital Association (AHA) and state hospital associations. Our team at Forvis Mazars also can share a version of the form upon request. Additional details about the process are available below.
When Should Providers Use This Process?
This process should be used for provider appeal complaints and claims payment disputes.
- Provider Appeal Complaint: Submitted by a contracted or non-contracted provider alleging an MA plan’s failure to follow the applicable appeals process. Noncompliance includes when an MA plan fails to alert the provider of the appeal process or fails to respond to a submitted appeal.
- Claims Payment Dispute: Provider’s dispute over the amount the MA plan paid for an approved service. Appealable decisions include those in which the plan partially approved claims or instances when submitted services were altered by the plan, e.g., downcoding, bundling, or approving at a lower level of care, resulting in a lower payment amount.
What Is the Process for Filing Complaints?
For each complaint, the provider must complete the cover sheet included in the instruction packet and submit documentation as indicated on the form. CMS may return complaints for correction if they include unnecessary information. The completed form should be submitted to medicarepartcdquestions@cms.hhs.gov.
If the representing organization does not meet the submission requirements, CMS will return the case(s) for correction before taking further action.
What Happens After Filing the Complaint?
CMS will direct the MA plan to investigate the case within 30 days and work directly with the provider toward resolution. To follow up on a complaint after submission, the representing organization should communicate directly with the MA plan. If the MA plan does not respond in a timely manner, the provider may contact the CMS office that received the complaint for a status update.
CMS staff will input the complaint into the Complaints Tracking Module and confirm receipt by providing a complaint ID for reference.
Why Did CMS Make This Change?
The centralized process described above allows the agency to identify trends in provider complaints, investigate matters as appropriate, and work with the MA plan to address issues.
CMS also clarifies that the 10 regional offices still maintain responsibility for MA plan oversight despite centralization of the complaint process.
What Healthcare Organizations Can Do
Healthcare organizations should implement a workflow for utilizing the new CMS complaint process. The workflow should be grounded in documented criteria developed by the revenue cycle team that govern when a claim should be submitted through the complaint process. If the provider is part of the MA plan’s network, a review of contract language for the plan in question should be a stage gate in the criteria. This not only helps the organization avoid submitting invalid complaints but also provides documentation to support the plan’s violation of its contractual obligation to the provider.
Finally, organizations should identify a single point of contact within the revenue cycle team who is responsible for final review and approval of claims based on the established criteria and will be listed on the complaint form.
If you have questions or need assistance with Medicare Advantage, please reach out to a professional at Forvis Mazars.