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Dual EligiblesGRIEVANCES & APPEALS
Grievances Medicaid
A Person Healthcare Files a Professional
Grievance
If not satisfied With Resolution
Documents Grievance
Attempts to Resolve Grievance
Writes up an acknowledgement of the Grievance within 5 days of
the grievance being filed
Mails it to Person filling the Grievance
Or or
Gives Copy to Person Filling the Grievance
Issue is Not Resolved within 30 days of Receipt
Issue is Resolved within 30 days of
Receipt
Status of the
Grievance is Mailed
Out
Mails Resolution Letter to Person
who filed the Grievance
Grievance is Resolved within 60 days of Receipt
Contacts Service Provider within 5 days of Receipt of
Resolution
Requests Additional
Consideration from DWMHA within 60
days
Grievances Medicare
A Person Healthcare Files a Professional
Grievance
If not satisfied With Resolution
Documents Grievance
Attempts to Resolve Grievance
Writes up an acknowledgement of the Grievance within 5 days of
the grievance being filed
Mails it to Person filling the Grievance
Or Or
Gives Copy to Person Filling the Grievance
Issue is Resolved within 30 days of
Receipt
Mails Resolution Letter to Person
who filed the Grievance
Client has 10 days to request review
of adverse grievance findings
Level One Appeal
Client is satisfied with resolution of
Grievance
No further actions required
Summary: Providers What You Need To Know
Medicare Medicaid
Grievances can originate at the Provider level or at the Authority Grievances can originate at the Provider Level, MCPN or at the Authority
Enrollees only have 60 days of an occurrence to file a grievance There is no time limit for filing a grievance
Resolution of grievance is not to exceed 30 days Resolution of grievance is not to exceed 60 days
Acknowledgement of grievance is required within 3 days of receipt Acknowledgement of grievance is required within 5 days of receipt
Enrollee may have an appointed representative to act on his/her behalf. Must have an Appointment of Representative (AOR) form on file.
Grievances can be filed by the enrollee or a legal representative; no specific form required as long as there is supporting documentation
If enrollee is not in agreement with the findings of the grievance, he/she may request a review by Independent Review Entity (IRE) in 10 days of resolution
If resolution of grievance is not completed within 60 days, an enrollee may request a Medicaid Fair Hearing
Appeals Medicare
Appeals Medicare - Continued
Summary: Providers What You Need to Know• Effective March 1, 2015 all Appeals were brought in house and are handled by Customer Service’s DWMHA Appeals Coordinator for resolution and
disposition.
• An Action that has resulted in an Appeal will require that providers generate within 24 hours all supporting documentation to DWMHA’s Appeals Coordinator for follow-up.
• The correct Action Notice form (Medicaid vs Medicare) needs to be generated by the Provider. Note a service may require both forms.
• Forms and Policies will be made available to all providers shortly.
• It is the provider’s responsibility to educate enrollees on their due process rights.
• React quickly to a problem, your efforts may often eliminate the need for an Appeal.
• Medicaid Appeals allow for 45 calendar days to resolve vs. Medicare which allows 30 days
• We will need you to provide a summary of all you dual eligible appeals to [email protected] monthly
Important Contacts
GRIEVANCES India Crockett313-833-7141
APPEALSPamela Oehmke
313-833-7216
Q&A
