Medicare Prescription Drug Appeals & Grievances
Guidance for The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 01, 2020
What's New
UPDATED PART C and D APPEALS GUIDANCE
11/20/2024: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate the regulatory change in the timeframe to submit an appeal from 60 calendar days to 65 days calendar days from the date of the notice.
The updates will be effective 01/01/2025. Questions related to the guidance or appeals policy may be submitted to the Division of Appeals Policy at https://appeals.lmi.org.
To access the guidance document, see the link to "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" in the “Downloads” section below.
Prescription Drug Grievances, Coverage Determinations and Appeals
Medicare Prescription Drug plans must meet the requirements for grievance, coverage determination, and appeals processing under the Part D regulations found at 42 CFR Part 423, Subpart M. For more information regarding grievances and various levels of appeal, please see the links on the left navigation menu on this page. Additional guidance is also in the "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance," in the “Downloads” section below.
Use the navigation menu on the left side of this page to link to web pages with more detailed information on Part D such as grievances, coverage determinations and exceptions, appeals, and other guidance.
Web Based Training Course Available for Part D
The course covers requirements for Part D coverage determinations, appeals, and grievances. Complete details and a link to the training module can be found on the "Training" page (link on the left navigation menu on this page).
Questions?
Questions regarding organization determinations, appeals and grievances can be submitted at: https://appeals.lmi.org
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.