THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
S U M M A R Y
DIARY: June 29, 2010 00:03 AM Tuesday;
Rod Welch
Received CMS regulations on HMO Grievance procedures for Millie's claim.
1...Summary/Objective
....Centers for Medicare & Medicaid...HHS........ 422.564...Page 385
........422.562 General provisions.
........422.564 Grievance procedures.
........422.566 Organization determinations.
..............
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CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 96 0000. ref SDS 95 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 010427 0830 meeting at Kaiser - Doctor Johnson notes Millie looks
040902 - so good nobody can believe she has such severe cancer, ref SDS 45
040903 - OJ6I; the doctor explained again Millie's cancer has mutated through
040904 - 11 relapses to resist chemotherapy. The doctor advised that Kaiser
040905 - has a new strategy prescribing therapy that is effective for treating
040906 - cancer as a chronic disease by "targeting" the genetic profile of
040907 - cancer that has mutated in patients, like Millie, to resist
040908 - chemotherapy. ref SDS 45 SJ6N
040910 - ..
040911 - On 100501 1037 Millie letter to medical team confirms understanding of
040912 - new strategy to treat Millie's cancer with targeted therapy.
040913 - ref SDS 46 F25O
040915 - ..
040916 - On 100501 2017 Doctor Rugo reports plans to collaborate with Doctor
040917 - Johnson at Kaiser on work plan for Millie to recover from 11th relapse
040918 - of cancer caused by UCSF medical mistakes. ref SDS 47 HH4I
040920 - ..
040921 - On 100502 2143 Kaiser confirms that some patients respond well to new
040922 - "targeted" therapies. ref SDS 48 YX8L Kaiser contends that all of the
040923 - strategies for "targeted" therapies have been executed for Millie,
040924 - which seems conflicting with the record in this case. ref SDS 48 MZ4N
040926 - ..
040927 - On 100503 1522 Millie notifies medical team that time of the essence
040928 - to get the next treatment going. ref SDS 49 TD5W
040930 - ..
040931 - On 100503 1945 Kaiser notifies Millie to get remaining 2 treatments
040932 - with Abraxane chemotherapy that seems to be failing, and then after 3
040933 - more weeks without treatment, following a trip abroad, the doctor will
040934 - discuss "next steps." ref SDS 50 YL5N
040936 - ..
040937 - On 100503 2338 Millie reports to medical team that she will implement
040938 - Kaiser's guidance to delay changing treatments, and takes Kaiser's
040939 - letter on 010503, as assurance that recovery will be equal to changing
040940 - treatment immediately on 100505. ref SDS 51 6X7S
040942 - ..
040943 - On 100504 1609 Sara, Practice Manager for the UCSF Oncology Breast
040944 - Care Clinic, called and notified Millie that Doctor Rugo will soon
040945 - communicate with Doctor Johnson, or had already done so, to coordinate
040946 - with Kaiser on planning Millie's next treatment to recover from the
040947 - 11th relapse of cancer. ref SDS 52 NT5N
040949 - ..
040950 - On 010505 0730 Millie received the 2nd treatment at Kaiser for the 3rd
040951 - cycle of Abraxane chemotherapy, as ordered by Doctor Johnson.
040952 - ref SDS 53 KE4K
040954 - ..
040955 - On 100511 0900 cancer marker CA 15-3 520 increased another 100 points,
040956 - seemingly on an accelerating rise, which threatens to cascade out of
040957 - control, because Abraxane chemotherapy is not effective. ref SDS 54
040958 - L54I
040960 - ..
040961 - On 100512 0730 Millie received 3rd treatment for 3rd cycle of
040962 - Abraxane. ref SDS 55 KE4K
040964 - ..
040965 - On 100515 1415 Millie departed 2-week trip to Europe. ref SDS 56 PK9O
040967 - ..
040968 - On 100527 0217 Millie files claim with Kaiser Claims Resolution
040969 - Department for standard of care to recover from 11th relapse of cancer
040970 - caused by medical mistakes getting radiation treatments at UCSF on
040971 - referral from Kaiser. ref SDS 57 IZ7N
040973 - ..
040974 - On 100528 0322 Millie requests support from Medicare to separate
040975 - recovery for medical mistakes getting radiation from UCSF, from health
040976 - care benefits limited by Medicare insurance coverage. ref SDS 58 QQ6N
040978 - ..
040979 - On 100528 1031 called Medicare they have formed a team to review
040980 - Millie's case, and contacted Kaiser's Claims Resolution Department for
040981 - response to Millie's claim. ref SDS 59 4W5F
040983 - ..
040984 - 100601 0830 Doctor Johnson reported that Kaiser has not had time to
040985 - collaborate with UCSF on treatment for Millie to recover from UCSF
040986 - medical mistakes. He discussed treating Millie with MPA, but this was
040987 - not prescribed because Millie was treated with MPA in 2009, and UCSF
040988 - ended the treatment due to fears about blood clot side effects, which
040989 - were believed to cause breathing problems Millie had, though later
040990 - breathing problems were discovered to be caused by defective radiation
040991 - treatment. Since Doctor Johnson said Kaiser has no more treatments
040992 - for Millie, the only way Millie can get relief from pain caused by
040993 - cancer that is progressing without treatment is get treatment in
040994 - Hospice. Since Hospice is the only choice of care offered today,
040995 - Millie accepted this.
040997 - ..
040998 - On 100601 1531 Sharon called to schedule starting Hospice medical
040999 - services beginning tomorrow between 0900 - 1000. ref SDS 46 036C
041001 - ..
041002 - On 100602 0913 Liz provides orientation on Hospice care; she confirms
041003 - Sharon's report yesterday, that if Kaiser performs on the insurance
041004 - agreement to provide standard of care for Millie's patient profile,
041005 - than Millie can elect to recover from 11th relapse of cancer, rather
041006 - than continue with Hospice support for dying peacefully. ref SDS 47
041007 - 036C
041009 - ..
041010 - On 100602 1046 Diane received notice from Medicare to file claim for
041011 - Millie to get treatment for recovering from UCSF medical mistakes; she
041012 - is preparing a statement of claim. ref SDS 64 036C Advised Diane to
041013 - use Millie's statement of claim submitted to Kaiser on 100527.
041014 - ref SDS 64 MZ5H Eileen called later and reported that Kaiser denied
041015 - Millie's claim on the grounds that Medicare does not authorize payment
041016 - for treatment to recover from cancer, after a patient starts Hospice.
041017 - ref SDS 64 UN4M Requested that Eileen read he claim and then make a
041018 - good faith determiantion. ref SDS 64 I33H Eileen called back after
041019 - reading the claim and advised the denial of claim has been withdrawn,
041020 - and the matter is referred to Claims Resolution Department.
041021 - ref SDS 64 UN5P
041023 - ..
041024 - On 100603 0449 Millie notified medical team that Kaiser called today
041025 - about moving forward to resolve medical mistakes getting radiation
041026 - treatment at UCSF on referral from Kaiser. ref SDS 65 IX9Q
041028 - ..
041029 - On 100606 1604 Doctor Johnson notifies Millie that her cancer marker
041030 - has remained fairly stable the past 3 weeks since ending treatment
041031 - with Abraxane on 100512; actually went up less without Abraxane, than
041032 - with it, because Millie's cancer resists chemotherapy. ref SDS 66 036C
041034 - ..
041035 - On 100606 1638 Millie thanks Doctor Johnson for submitting good news
041036 - cancer marker CA 15-3 606 much smaller rise than exptected after
041037 - ending treatment for 3 weeks. ref SDS 67 036C; asks if Doctor Rugo ever
041038 - returned Doctor Johnson's call from Kaiser, as planned in Doctor
041039 - Rugo's letter on 100501?
041041 - ..
041042 - On 100606 2317 Millie receives letter from Doctor Johnson reporting
041043 - that Doctor Rugo has never returned his call asking UCSF for Millie's
041044 - treatment plan, which demonstrates failure to perform on Doctor Rugo's
041045 - commitment in UCSF letter sent to the medical team on 100501.
041046 - ref SDS 68 036C
041048 - ..
041049 - On 100607 0932 called Cherry at Medicare about progress on contacting
041050 - Kaiser to process Millie's claim filed on 100527, and planned in the
041051 - call with Medicare (Cherry and Beth) as action item #8, planned the
041052 - next day on 100528 1031, ref SDS 59 PE6P; today, Cherry did not have
041053 - time to return the call. ref SDS 69 036C
041055 - ..
041056 - On 100607 1021 called Paula at Kaiser - she said someone else is
041057 - handling Millie's claim, because the claim has not been denied, and
041058 - Paula only handles denied claims. ref SDS 70 036C; Paula further
041059 - reported that Kaiser no longer objects to demaning UCSF correct
041060 - medical mistakes, so Millie's claim should be easy to resolve.
041061 - ref SDS 70 QN9F
041063 - ..
041064 - On 100607 1117 letter to Paula confirming Kaiser's work plan to
041065 - process Millie's claim for care promptly in order to save her life.
041066 - ref SDS 71 036C
041068 - ..
041069 - On 100608 1521 called and talked to Cherry and Beth about expediting
041070 - Millie's claim at Kaiser. ref SDS 72 036C Developed work plan to have
041071 - a conference call with Kaiser tomorrow. ref SDS 72 C354 Submitted
041072 - letter to Kasier and CMS Medicare confirming work plan for tomorrow.
041073 - ref SDS 72 G84Q
041075 - ..
041076 - On 100609 1114 called CMS to expedite conference call on expediting
041077 - Millie's care. ref SDS 73 036C Cherry called and schedule telecon with
041078 - Kaiesr and CMS today 1300. ref SDS 73 8O4H Received letter from Cherry
041079 - at CMS confirming work plan for conference call at 1300. ref SDS 73
041080 - PRXY
041082 - ..
041083 - On 100609 1232 letter to CMS and Kaiser submitts agenda for conference
041084 - call to review progress on Kaiser resolving Millie's claim for
041085 - recovery from UCSF medical mistakes. ref SDS 74 036C
041087 - ..
041088 - On 100609 1300 CMS and Kaiser conference call to report progress on
041089 - reviewing Millie's claim for treatment to recover from UCSF medical
041090 - mistakes in time to be effective. ref SDS 75 036C
041092 - ..
041093 - On 100609 1522 Jennifer called for assistance processing Millie's
041094 - claim to recover from medical mistakes getting radiation treatment at
041095 - UCSF on referral from Kaiser. ref SDS 76 036C
041097 - ..
041098 - On 100611 1451 Jennifer advised Kaiser extended the date for
041099 - responding to Millie's claim from 100610 to 100624, based on Millie
041100 - filing updated statement of authorized representative. ref SDS 80 036C
041101 - Jennifer reported she reviewed 6-issues discussed on 100609, and will
041102 - address these issues responding to Millie's claim. ref SDS 80 FQ4G
041103 - Jennifer asked how Kaiser can treat Millie to recover from UCSF
041104 - medical mistakes, if Millie refuses chemotherapy and has entered
041105 - Hospice. ref SDS 80 FQ4M
041107 - ..
041108 - On 100611 2326 Millie received Jennifer's letter confirming the date
041109 - for Kaiser to respond to Millie's claim has been extended to 100624,
041110 - ref SDS 81 CV4O, and further advising that issues Kaiser will determine
041111 - responding to Millie's claim for recovering from UCSF medical
041112 - mistakes, ref SDS 81 036C, are as set out in the record for telecon on
041113 - 100609. ref SDS 76 XK50 Jennifer will call on 100615, to report
041114 - progress on respnding to Millie's claim. ref SDS 81 6P53
041116 - ..
041117 - On 100614 0257 letter to Kaiser Medicar CMS claim team requests
041118 - immediate written proposal evaluating treatment options for Millie to
041119 - consider. ref SDS 82 036C
041121 - ..
041122 - On 100616 0832 called Jennifer about her plan to call yesterday on
041123 - Tuesday to report progress Kaiser responding to Millie's claim, as set
041124 - out in Jennifer's letter on 100611. ref SDS 83 036C Jennifer called
041125 - back to ask if Millie wants UCSF or Kaiser to pay for her damages
041126 - caused by UCSF medical mistakes. ref SDS 83 PSSV Jennifer reported
041127 - delays communicating with Millie's medical team have delayed making
041128 - arrangements for Millie to start treatment recovering from UCSF
041129 - medical mistakes. ref SDS 83 OY4T She plans to call on Friday, 100618,
041130 - to report progress responding to Millie's claim. ref SDS 83 1K5J
041132 - ..
041133 - On 100618 0843 called Jennifer at Memeber Case Resolution Department
041134 - about progress responding to Millie's claim. ref SDS 84 036C
041136 - ..
041137 - On 100620 1112 letter to Kaiser claim team with copy to Medicare, and
041138 - the medical team requests call on Monday 100621, planned for previous
041139 - Friday, 100628, to report progress getting Millie treatment.
041140 - ref SDS 85 036C Recommends that delay communicating with medical team
041141 - that has delayed Millie starting treatment in time to be effective,
041142 - ref SDS 85 L59P, can be solved by hiring MD Anderson. ref SDS 85 L59X
041144 - ..
041145 - On 100621 0853 called for Jennifer and left several messages,
041146 - including for her team lead. ref SDS 87 036C Nobody had time today
041147 - for calling back. ref SDS 87 OP3N
041149 - ..
041150 - On 100622 1027 Jennifer called and advised that Doctor Johnson
041151 - responded to request for comment on Millie's claim saying he cannot
041152 - provide care for Millie because she entered Hospice on 100601,
041153 - ref SDS 89 036C; recommended Jennifer check Kaiser's medical chart for
041154 - Millie meeting with Doctor Johnson to see Millie was given no choices
041155 - except to enter Hospice in order to avoid further pain and suffering.
041156 - ref SDS 89 NX68
041158 - ..
041159 - On 100622 1511 letter to claim team and Medicare, and to Millie's
041160 - medical team confirming understanding in Jennifer's call that Millie's
041161 - medical team at Kaiser seems to refuse Millie standard of care to
041162 - recover from UCSF medical mistakes, because she was forced to enter
041163 - Hospice to get relief from pain caused by UCSF medical mistakes.
041164 - ref SDS 90 036C UCSF delays compounded Millie's injuries, pain, and
041165 - suffering; caution must be exercised to enable recovery, based on
041166 - Millie's right to life. ref SDS 90 575U Millie's patient history
041167 - shows the doctor's only issue, ref SDS 90 576V, is having time to
041168 - providing standard of care for Millie to recover from medical
041169 - mistakes, and if not, then Kaiser should assign someone who does.
041170 - ref SDS 90 583Y Kaiser has violated Millie's human rights; a woman's
041171 - right to choose life for herself, should be no less than the right to
041172 - choose for her unborn child, since the right to life and due process
041173 - are protected by the US Constitution. ref SDS 90 584W Kaiser can
041174 - easily solve the time problem by hiring other people to do the work,
041175 - and charging UCSF. ref SDS 90 585P
041177 - ..
041178 - 100624 1616 Jennifer called and asked to extend Kaiser's response to
041179 - Millie's claim another day or so, for review with her boss, and with
041180 - the customer. ref SDS 91 036C Jennifer the original date for Kaiser to
041181 - respond on 100610, required by statute, and then amended to today on
041182 - 100624, can be further amended, and cited unclear authority about 30
041183 - days instead of 14. ref SDS 91 EG5P Agreed that extending Kaiser's
041184 - response another few days until tomorrow, or Monday, is an acceptable
041185 - risk, even though Millie's cancer markier has increased significantly
041186 - to over 1000, and so that an equitable solution can be implented that
041187 - allows treatment in time to be effective for Millie. ref SDS 91 EG73
041188 - Jennifer will submit her draft response, and call tomorrow for
041189 - discussing Kaiser's solution. ref SDS 91 H98M
041191 - ..
041192 - On 100625 0852 letter to Kaiser and Medicare claim teams confirming
041193 - Kaiser's request to extend date for responding to Millie's claim
041194 - another few days until Monday in order to get comprehensive solution.
041195 - ref SDS 92 036C
041197 - ..
041198 - On 100626 0917 received letter from Cherry at Medicare, ref SDS 93
041199 - 036C, submitting CMS regulations, that control due date for Kaiser to
041200 - respond to Millie's claim. ref SDS 93 N64I
041202 - ..
041203 - On 100628 0228 letter to claim teams at Medicare and Kaiser asking how
041204 - CMS regulations received on 100625, apply to extend Kaiser's response
041205 - date for expediting Millie's recovery. ref SDS 94 036C
041207 - ..
041208 - On 100628 1033 called CMS Medicare for Beth Simone on regulations for
041209 - Kaiser to respond to Millie's claim.
041211 - ..
041212 - On 100628 2318 submitted record of telecon with CMS, ref SDS 96 036C,
041213 - and that CMS learned today that Kaiser changed Millie's claim to a
041214 - Grievance, and notified CMS that Kaiser intends to delay response
041215 - until 100710, to Millie's claim filed on 100527.
041217 - ..
041218 - On 100629 00003 received letter from Cherry transmitting Grievance
041219 - procedures, cited in the telecon yesterday as a change Kaiser made to
041220 - delay responding until 100710, to Millie's claim filed on 100527.
041221 - ref SDS 0 036C Review of Grievance regulations show Kaiser required
041222 - to make timely response based on patient health. ref SDS 0 PN5S
041223 -
041224 -
041226 - ..
0413 -
0414 -
0415 - Progress
0416 -
041601 - CMS letter from Cherry says...
041602 -
041603 - 1. Subject: CMS regulation for Medicare grievance
041604 - Date: Mon, 28 Jun 2010 21:21:25 -0400
041612 - ..
041613 - 2. Per your request [...in telecon with CMS on 100628 1033.
041614 - ref SDS 95 RO9X...] please see attachment for details of the
041615 - citation 42 CFR 422.564(e) (1) and (2) describing the
041616 - timeframe for MA organization's response for grievance.
041617 - ref SDS 0 TQ5T
041618 -
041619 - [On 100629 0013 notified CMS regulations were received, and
041620 - support CMS work plan to requerst compliance from Kaiser.
041621 - ref SDS 97 3Y5V
041623 - ..
041624 - 3. [Extracted from 42 CFR 422.564(e) (1. and (2)]
041625 -
041626 - (e) Grievance disposition and notification.
041627 -
041628 - (1) The MA organization must notify the enrollee of its
041629 - decision as expeditiously as the case requires, based
041630 - on the enrollee's health status, but no later than 30
041631 - days after the date the organization receives the oral
041632 - or written grievance. ref SDS 0 TQ5T
041634 - ..
041635 - This section says 30 days is the maximum response time, and requires
041636 - early response to prevent injuring patient health.
041638 - ..
041639 - CMS regulations continue...
041640 -
041641 - (2) The MA organization may extend the 30-day timeframe by
041642 - up to 14 days if the enrollee requests the extension
041643 - or if the organization justifies a need for additional
041644 - information and documents how the delay is in the
041645 - interest of the enrollee. When the MA organization
041646 - extends the deadline, it must immediately notify the
041647 - enrollee in writing of the reasons for the delay.
041648 - ref SDS 0 TQ6T
041650 - ..
041651 - 4. We will get back to you tomorrow with answer to your additional
041652 - questions per telephone conversation today.
041653 -
041659 -
041660 - Attachment
041662 - ..
041663 - 42 CFR 422.564(e) (1).............. ref SDS 0 TQ5T
041664 - and (2).............. ref SDS 0 TQ6T
041665 -
041666 - **********************************************
041667 -
041668 - Centers for Medicare & Medicaid...HHS........ 422.564...Page 385
041670 - ..
041671 - appeals process, subject to the applicable rules described in
041672 - part 405 of this chapter.
041674 - ..
041675 - [63 FR 35067, June 26, 1998, as amended at 65 FR 40328, June
041676 - 29, 2000; 68 FR 16667, Apr. 4, 2003; 70 FR 4738, Jan. 28, 2005]
041678 - ..
041679 - 422.562 General provisions.
041680 -
041681 - (a) Responsibilities of the MA organization.
041683 - ..
041684 - (1) An MA organization, with respect to each MA plan that
041685 - it offers, must establish and maintain-
041687 - ..
041688 - (i)A grievance procedure as described in 422.564
041689 - for addressing issues that do not involve
041690 - organization determinations;
041692 - ..
041693 - (ii)A procedure for making timely organization
041694 - determinations;
041696 - ..
041697 - (iii)Appeal procedures that meet the requirements of
041698 - this subpart for issues that involve organization
041699 - determinations; and
041701 - ..
041702 - (2) An MA organization must ensure that all enrollees
041703 - receive written information about the-
041704 -
041705 - (i)Grievance and appeal procedures
041706 - that are available to them through the
041707 - MA organization; and
041708 -
041709 - (ii)Complaint process available to
041710 - the enrollee under the QIO process as
041711 - set forth under section 1154(a)(14) of the
041712 - Act.
041714 - ..
041715 - (3) In accordance with subpart K of this part, if the MA
041716 - organization delegates any of its responsibilities
041717 - under this subpart to another entity or individual
041718 - through which the organization provides health care
041719 - services, the MA organization is ultimately
041720 - responsible for ensuring that the entity or
041721 - individual satisfies the relevant requirements of
041722 - this subpart.
041724 - ..
041725 - (b) Rights of MA enrollees. In accordance with the provisions
041726 - of this subpart, enrollees have the following rights:
041728 - ..
041729 - (1) The right to have grievances between the enrollee and
041730 - the MA organization heard and resolved, as described
041731 - in 422.564.
041733 - ..
041734 - (2) The right to a timely organization determination, as
041735 - provided under 422.566.
041737 - ..
041738 - (3) The right to request an expedited organization
041739 - determination, as provided under 422.570.
041741 - ..
041742 - (4) If dissatisfied with any part of an organization
041743 - determination, the following appeal rights:
041745 - ..
041746 - (i)The right to a reconsideration of the adverse
041747 - organization determination by the MA organization, as
041748 - provided under 422.578.
041750 - ..
041751 - (ii)The right to request an expedited
041752 - reconsideration, as provided under 422.584.
041754 - ..
041755 - (iii)If, as a result of a reconsideration, an MA
041756 - organization affirms, in whole or in part, its
041757 - adverse organization determination, the right to an
041758 - automatic reconsidered determination made by an
041759 - independent, outside entity contracted by CMS, as
041760 - provided in 422.592.
041762 - ..
041763 - (iv)The right to an ALJ hearing if the amount in
041764 - controversy is met, as provided in 422.600.
041766 - ..
041767 - (v)The right to request MAC review of the ALJ hearing
041768 - decision, as provided in 422.608.
041770 - ..
041771 - (vi)The right to judicial review of the hearing
041772 - decision if the amount in controversy is met, as
041773 - provided in 422.612.
041775 - ..
041776 - (c) Limits on when this subpart applies.
041778 - ..
041779 - (1) If an enrollee receives immediate QIO review (as
041780 - provided in 422.622) of a determination of
041781 - noncoverage of inpatient hospital care-
041783 - ..
041784 - (i)The enrollee is not entitled to review of that
041785 - issue by the MA organization; and
041787 - ..
041788 - (ii)The QIO review decision is subject only to the
041789 - appeal procedures set forth in parts 476 and 478 of
041790 - this chapter.
041792 - ..
041793 - (2) If an enrollee has no further liability to pay for
041794 - services that were furnished by an MA organization, a
041795 - determination regarding these services is not subject
041796 - to appeal.
041798 - ..
041799 - (d) When other regulations apply.
041800 -
041801 - Unless this subpart provides otherwise, the regulations in
041802 - part 405 of this chapter (concerning the administrative
041803 - review and hearing processes and representation of parties
041804 - under titles II and XVIII of the Act), apply under this
041805 - subpart to the extent they are appropriate.
041807 - ..
041808 - [63 FR 35067, June 26, 1998, as amended at 65 FR 40329, June
041809 - 29, 2000; 70 FR 4738, Jan. 28, 2005; 70 FR 52027, Sept. 1,
041810 - 2005]
041811 -
041813 - ..
041814 - 422.564 Grievance procedures.
041815 -
041816 - (a) General rule.
041817 -
041818 - Each MA organization must provide meaningful procedures
041819 - for timely hearing and resolving grievances between
041820 - enrollees and the organization or any other entity or
041821 - individual through which the organization provides health
041822 - care services under any MA plan it offers.
041824 - ..
041825 - (b) Distinguished from appeals.
041826 -
041827 - Grievance procedures are separate and distinct from appeal
041828 - procedures, which address organization determinations as
041829 - defined in 422.566(b). Upon receiving a complaint, an
041830 - MA organization must promptly determine and inform the
041831 - enrollee whether the complaint is subject to its grievance
041832 - procedures or its appeal procedures.
041834 - ..
041835 - (c) Distinguished from the quality improvement organization
041836 - (QIO) complaint process.
041838 - ..
041839 - Under section 1154(a)(14) of the Act, the QIO must review
041840 - beneficiaries' written complaints about the quality of
041841 - services they have received under the Medicare program.
041842 - This process is separate and distinct from the grievance
041843 - procedures of the MA organization.
041845 - ..
041846 - For quality of care issues, an enrollee may file a
041847 - grievance with the MA organization; file a written
041848 - complaint with the QIO, or both.
041850 - ..
041851 - For any complaint submitted to a QIO, the MA organization
041852 - must cooperate with the QIO in resolving the complaint.
041854 - ..
041855 - (d) Method for filing a grievance.
041856 -
041857 - (1) An enrollee may file a grievance with the MA
041858 - organization either orally or in writing.
041859 -
041860 - (2) An enrollee must file a grievance
041861 - no later than 60 days after the event or
041862 - incident that precipitates the grievance.
041864 - ..
041865 - (e) Grievance disposition and notification.
041867 - ..
041868 - (1) The MA organization must notify the enrollee of its
041869 - decision as expeditiously as the case requires, based
041870 - on the enrollee's health status, but no later than 30
041871 - days after the date the organization receives the
041872 - oral or written grievance.
041874 - ..
041875 - (2) The MA organization may extend the 30-day timeframe
041876 - by up to 14 days if the enrollee requests the
041877 - extension or if the organization justifies a need for
041878 - additional information and documents how the delay is
041879 - in the interest of the enrollee. When the MA
041880 - organization extends the deadline, it must
041881 - immediately notify the enrollee in writing of the
041882 - reasons for the delay.
041884 - ..
041885 - (3) The MA organization must inform the enrollee of the
041886 - disposition of the grievance in accordance with the
041887 - following procedures:
041889 - ..
041890 - (i)All grievances submitted in writing must be
041891 - responded to in writing.
041893 - ..
041894 - (ii)Grievances submitted orally may be responded to
041895 - either orally or in writing, unless the enrollee
041896 - requests a written response.
041898 - ..
041899 - (iii)All grievances related to quality of care,
041900 - regardless of how the grievance is filed, must be
041901 - responded to in writing. The response must include a
041902 - description of the enrollee's right to file a written
041903 - complaint with the QIO. For any complaint submitted
041904 - to a QIO, the MA organization must cooperate with the
041905 - QIO in resolving the complaint.
041907 - ..
041908 - (f) Expedited grievances.
041909 -
041910 - An MA organization must respond to an enrollee's grievance
041911 - within 24 hours if:
041913 - ..
041914 - (1) The complaint involves an MA organization's decision
041915 - to invoke an extension relating to an organization
041916 - determination or reconsideration.
041918 - ..
041919 - (2) The complaint involves an MA organization's refusal
041920 - to grant an enrollee's request for an expedited
041921 - organization determination under 422.570 or
041922 - reconsideration under 422.584.
041924 - ..
041925 - (g) Recordkeeping.
041926 -
041927 - The MA organization must have an established process to
041928 - track and maintain records on all grievances received both
041929 - orally and in writing, including, at a minimum, the date
041930 - of receipt, final disposition of the grievance, and the
041931 - date that the MA organization notified the enrollee of the
041932 - disposition.
041934 - ..
041935 - [68 FR 16667, Apr. 4, 2003, as amended at 70 FR 4738, Jan. 28,
041936 - 2005]
041937 -
041939 - ..
041940 - 422.566 Organization determinations.
041941 -
041942 - (a) Responsibilities of the MA organization.
041943 -
041944 - Each MA organization must have a procedure for making
041945 - timely organization determinations (in accordance with the
041946 - requirements of this subpart) regarding the benefits an
041947 - enrollee is entitled to receive under an MA plan,
041948 - including basic benefits as described under
041949 - 422.100(c)(1) and mandatory and optional supplemental
041950 - benefits as described under 422.102, and the amount, if
041951 - any, that the enrollee is required to pay for a health
041952 - service. The MA organization must have a standard
041953 - procedure for making determinations, in accordance with
041954 - 422.568, and an expedited procedure for situations in
041955 - which
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