[Code of Federal Regulations] [Title 42, Volume 3] [Revised as of October 1, 2006] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR422.562] [Page 324-325] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents Subpart M_Grievances, Organization Determinations and Appeals Sec. 422.562 General provisions. (a) Responsibilities of the MA organization. (1) An MA organization, with respect to each MA plan that it offers, must establish and maintain-- (i) A grievance procedure as described in Sec. 422.564 for addressing issues that do not involve organization determinations; (ii) A procedure for making timely organization determinations; (iii) Appeal procedures that meet the requirements of this subpart for issues that involve organization determinations; and (2) An MA organization must ensure that all enrollees receive written information about the-- (i) Grievance and appeal procedures that are available to them through the MA organization; and (ii) Complaint process available to the enrollee under the QIO process as set forth under section 1154(a)(14) of the Act. (3) In accordance with subpart K of this part, if the MA organization delegates any of its responsibilities under this subpart to another entity or individual through which the organization provides health care services, the MA organization is ultimately responsible for ensuring that the entity or individual satisfies the relevant requirements of this subpart. (b) Rights of MA enrollees. In accordance with the provisions of this subpart, enrollees have the following rights: (1) The right to have grievances between the enrollee and the MA organization heard and resolved, as described in Sec. 422.564. (2) The right to a timely organization determination, as provided under Sec. 422.566. (3) The right to request an expedited organization determination, as provided under Sec. 422.570. (4) If dissatisfied with any part of an organization determination, the following appeal rights: (i) The right to a reconsideration of the adverse organization determination by the MA organization, as provided under Sec. 422.578. (ii) The right to request an expedited reconsideration, as provided under Sec. 422.584. (iii) If, as a result of a reconsideration, an MA organization affirms, in whole or in part, its adverse organization determination, the right to an automatic reconsidered determination made by an independent, outside entity contracted by CMS, as provided in Sec. 422.592. (iv) The right to an ALJ hearing if the amount in controversy is met, as provided in Sec. 422.600. (v) The right to request MAC review of the ALJ hearing decision, as provided in Sec. 422.608. (vi) The right to judicial review of the hearing decision if the amount in controversy is met, as provided in Sec. 422.612. (c) Limits on when this subpart applies. (1) If an enrollee receives immediate QIO review (as provided in Sec. 422.622) of a determination of noncoverage of inpatient hospital care-- (i) The enrollee is not entitled to review of that issue by the MA organization; and (ii) The QIO review decision is subject only to the appeal procedures set forth in parts 476 and 478 of this chapter. [[Page 325]] (2) If an enrollee has no further liability to pay for services that were furnished by an MA organization, a determination regarding these services is not subject to appeal. (d) When other regulations apply. Unless this subpart provides otherwise, the regulations in part 405 of this chapter (concerning the administrative review and hearing processes and representation of parties under titles II and XVIII of the Act), apply under this subpart to the extent they are appropriate. [63 FR 35067, June 26, 1998, as amended at 65 FR 40329, June 29, 2000; 70 FR 4738, Jan. 28, 2005; 70 FR 52027, Sept. 1, 2005]