Medicare Compliance & Reimbursement

Medicare+Choice organizations will have to notify enrollees two days prior to terminating services under a new set of appeal and grievance rules issued by the Centers for Medicare & Medicaid Services April 4.

That's down from the four days CMS originally suggested in a 2001 proposed rule on the subject. The agency explains that four days is too far in advance to predict when an enrollee's need for coverage would end.

The final rule, which is the end result of the high profile class action lawsuit Grijalva v. Shalala, also gives M+C enrollees the right to an immediate review of M+C coverage decisions by an independent body; requires M+COs to give enrollees instructions on how to appeal when services are terminated; and mandates that, upon request, plans offer enrollees detailed, specific explanations of why the plan believes services are no longer medically necessary or no longer covered.

To see the rule, go to http://www.access.gpo.gov/su_docs/fedreg/a030404c.html.