OCMM Appeals and Grievances for Medicare Advantage Plans

This module defines and explains the differences between an appeal and a grievance and explains the responsibilities of the Care Delivery Organization regarding the appeals process. It also defines time frame requirements regarding appeals and grievances and how to effectuate appeal overturns according to the UnitedHealthcare (UHC) Care Provider Administrative Guide and the Centers for Medicare & Medicaid Services (CMS) Guidelines.  

Case Study Review of Appeals 

This supplemental module, which has been paired with the Appeals and Grievances module, offers case studies and introduces you to common reasons for overturns, including a rationale for each example.   

Course Last Reviewed: 3/7/2022

Target Audience

Medical Directors

Registered Nurses

 

Learning Objectives

• Describe the Care Delivery Organization (CDO) requirements for submitting a grievance.
• Explain the Care Delivery Organization (CDO) responsibilities as they relate to the appeals process.
• Compare the appeal time frame requirements for different types of requests.
• Discuss how to effectuate appeal overturns according to the UnitedHealthcare (UHC) Care Provider Administrative Guide and the Centers for Medicare & Medicaid Services (CMS) Guidelines.
• Identify strategies to prevent unnecessary appeals and overturns.

Course summary
Course opens: 
03/30/2021
Course expires: 
02/01/2027
Cost:
$0.00

Price

Cost:
$0.00
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