Subpart M. Subpart M—Grievances, Organization Determinations and Appeals

• § 422.560 - Basis and scope.
• § 422.561 - Definitions.
• § 422.562 - General provisions.
• § 422.564 - Grievance procedures.
• § 422.566 - Organization determinations.
• § 422.568 - Standard timeframes and notice requirements for organization determinations.
• § 422.570 - Expediting certain organization determinations.
• § 422.572 - Timeframes and notice requirements for expedited organization determinations.
• § 422.574 - Parties to the organization determination.
• § 422.576 - Effect of an organization determination.
• § 422.578 - Right to a reconsideration.
• § 422.580 - Reconsideration defined.
• § 422.582 - Request for a standard reconsideration.
• § 422.584 - Expediting certain reconsiderations.
• § 422.586 - Opportunity to submit evidence.
• § 422.590 - Timeframes and responsibility for reconsiderations.
• § 422.592 - Reconsideration by an independent entity.
• § 422.594 - Notice of reconsidered determination by the independent entity.
• § 422.596 - Effect of a reconsidered determination.
• § 422.600 - Right to a hearing.
• § 422.602 - Request for an ALJ hearing.
• § 422.608 - Medicare Appeals Council (Council) review.
• § 422.612 - Judicial review.
• § 422.616 - Reopening and revising determinations and decisions.
• § 422.618 - How an MA organization must effectuate standard reconsidered determinations or decisions.
• § 422.619 - How an MA organization must effectuate expedited reconsidered determinations.
• § 422.620 - Notifying enrollees of hospital discharge appeal rights.
• § 422.622 - Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
• § 422.624 - Notifying enrollees of termination of provider services.
• § 422.626 - Fast-track appeals of service terminations to independent review entities (IREs).

• Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans

  • SECTION § 422.629 - General requirements for applicable integrated plans.
  • SECTION § 422.630 - Integrated grievances.
  • SECTION § 422.631 - Integrated organization determinations.
  • SECTION § 422.632 - Continuation of benefits while the applicable integrated plan reconsideration is pending.
  • SECTION § 422.633 - Integrated reconsiderations.
  • SECTION § 422.634 - Effect.