100-11 Programs of All-Inclusive Care for the Elderly (PACE)Manual: Chapter 11 - Grievances and Appeals

Programs of All-Inclusive Care for the
Elderly (PACE)
Chapter 11 – Grievances and Appeals
Table of Contents
(Rev. 2, Issued: 06-09-11)
Transmittals for Chapter 11
10 - Grievances
20 - Appeals
20.1 - Internal Processes
20.2 - Standard
20.3 - Expedited Appeals
20.4 - Additional Appeal Rights Under Medicare or Medicaid
20.5 – Medicare-Only
20.6 - Medicaid

10 - Grievances
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
A grievance is defined as a complaint, either written or oral, expressing
dissatisfaction with the service delivery or the quality of care furnished.
The PACE organization must have a formal written process to evaluate and resolve
grievances, whether medical or non-medical in nature, by PACE participants, their family
members or representatives. All personnel (employees and contractors) who have contact
with participants should be aware of and understand the basic procedures for receiving
and documenting grievances in order to initiate the appropriate process for resolving
participant concerns. All participants must be informed of the grievance process in
writing upon enrollment into the PACE program and at least annually thereafter.
The PACE organization’s grievance process, at a minimum, must include written
procedures for the following:
• 	How a participant files a grievance;
• 	Documentation of a participant’s grievance;
• 	Response to, and resolution of, the grievance in a timely manner;
• 	Maintenance of the participant’s confidentiality throughout the grievance
process and thereafter.
The PACE organization’s internal procedures should assure that every grievance is
handled in a uniform manner and that there is communication among different
individuals who are responsible for reviewing or resolving grievances. In addition, the
PACE organization must maintain appropriate documentation so the information can be
utilized in the organization’s QAPI program.
The PACE organization must discuss with, and provide to the participant, in writing, the
specific steps, including timeframes for response, that will be taken to resolve the
participant’s grievance. It is expected that each PACE organization have a process
prepared to acknowledge a beneficiary grievance with timeframes and additional
information on the process; for example, a participant grievance form to acknowledge the
grievance and a letter of resolution informing the participant of the grievance outcome.
The PACE organization must continue providing all required care to the enrolled
participant throughout the grievance process. The PACE organization must maintain,
aggregate and analyze the information on the grievance process. This information must
be utilized as part of the organization’s internal QAPI program. Through analyzing the
filed grievances there may be an opportunity for process improvement, which could lead
to improved quality of care for the participants.
[42 CFR § 460.120; 71 FR 71300 (Dec. 8, 2006)]

20 - Appeals
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
An appeal is defined as a participant’s action taken with respect to the PACE
organization’s non-coverage of, or nonpayment for a service, including denials,
reductions, or termination of services.
The PACE organization must have a formal, written appeals process including
timeframes for response to address non-coverage or nonpayment of a service. All
participants must be provided written information regarding the appeals process upon
enrollment, at least annually thereafter, and whenever the IDT denies a request for
services or payment. It is expected that each PACE organization have a template prepared
to assist the participant in filing an appeal, with written notification to acknowledge that a
participant has appealed with the required timeframes and additional information on the
process, and a notice of action providing the appeal outcome and information on the next
level of appeal.
The information on appeals proceedings will be maintained, aggregated and analyzed by
the organization. This process will be utilized as part of the organization’s internal QAPI
program. Through analyzing the filed appeals, there may be an opportunity for process
improvement which could lead to improved quality of care for the participants.
[42 CFR § 460.122(a), (b), and (i); 71 FR 71301 (Dec. 8, 2006)]
20.1 - Internal Processes
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
20.2 - Standard
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization’s internal appeals process, at a minimum, must include written
procedures for:
• 	Timely preparation and processing of written denials of coverage or payment;
• 	Filing a participant’s appeal;
• 	Documenting the participant’s appeal;
• 	Appointing an appropriately credentialed and impartial third party who was
not involved in the original decision and who does not have a stake in the
outcome of the appeal to review the participant’s appeal (this may include
employees or contractors of the PACE organization through a review
committee);

• 	Responding to and resolving the participant’s appeals as expeditiously as the
participant’s health condition requires, but no later than 30 calendar days after
the PACE organization receives an appeal; and
• 	Maintaining confidentiality of participant appeals.
The PACE organization must give all parties involved in the appeal appropriate written
notification and a reasonable opportunity to present evidence related to the dispute in
person as well as in writing.
The PACE organization must continue to furnish care to the participant during the appeal
process. Specifically, during the appeals process, the PACE organization must meet the
following requirements:
• 	For a Medicaid participant, continue to furnish the disputed services until
issuance of the final determination if the following conditions are met: (1) the
PACE organization is proposing to terminate or reduce services currently
being furnished to the participant; and (2) the participant requests
continuation with the understanding that he or she may be liable for the costs
of the contested services if the determination is not made in his or her favor.
Although not required by the regulation, an organization can also furnish
disputed services during an appeal for a Medicare participant.
• 	Continue to furnish to the participant all other required services as specified in
subpart F of Part 460.
[42 CFR § 460.122(c), (d), and (e)]
20.3 - Expedited Appeals
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
In addition to the standard appeals process, the PACE organization must have an
expedited appeals process in place for situations in which the participant believes that if
the service is not furnished, his or her life, health, or ability to regain or maintain
maximum function would be seriously jeopardized.
The PACE organization must respond to the appeal as expeditiously as the participant’s
health condition requires, but no later than 72 hours after it receives the appeal. The 72-
hour timeframe may be extended by up to 14 calendar days if the participant requests the
extension or the PACE organization justifies to the State Administering Agency the need
for additional information and how the delay is in the interest of the participant.
The PACE organization must take appropriate action to furnish the disputed service as
expeditiously as the health condition of the participant requires if, on appeal, a
determination is made in favor of the participant.

The PACE organization is required to notify CMS, the State Administering Agency, and
the participant of its determination that is wholly or partially adverse to a participant at
the time the decision is made. CMS notification may be accomplished through the HPMS
Data Element for monitoring reporting.
[42 CFR § 460.122(f), (h), and (g)]
20.4 - Additional Appeal Rights Under Medicare or Medicaid
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The external appeals process provides participants with an appropriate external review
depending on their Medicare and Medicaid status. Medicare beneficiaries have access to
the Medicare external appeals route through the Independent Review Entity (IRE) that
contracts with CMS, while Medicaid-eligible individuals have access to the State Fair
Hearing process. In those cases where participants are covered only under one program
(Medicare or Medicaid), only the applicable appeals process would apply. PACE
participants who are dually eligible for both Medicare and Medicaid have the choice of
either process, however, they may only choose one route by which to exercise their
external appeal rights. Allowing dually eligible participants to choose to pursue an appeal
through either the Medicare’s IRE or Medicaid’s State Fair Hearing processes eliminates
the possibility of conflicting determinations. Therefore, all PACE participants have one
route by which to exercise their external appeal rights. A PACE organization must inform
a participant in writing of his or her appeal rights under Medicare or Medicaid managed
care, or both, assist the participant in choosing which to pursue if both are applicable, and
forward the appeal to the appropriate external entity.
The PACE organization must continue to furnish the disputed services to the participant
during the appeal process because Sections 1894(a)(1)(B)(i) and 1934(a)(1)(B)(i) of the
Act requires that participants receive benefits solely through the PACE organization and,
as explained in 42 CFR § 460.98(a), the required services for a participant are those
services identified in their plan of care.
[42 CFR § 460.124; 71 FR 71303 (Dec. 8, 2006)]
20.5 – Medicare-Only
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Medicare does not have an external appeals process that permits challenges of enrollment
denials or disenrollment determinations for Medicare-only beneficiaries within PACE. A
Medicare-only eligible participant will need to use the appeals process that States are
required to provide for enrollment/disenrollment decisions.
More information on the Medicare IRE process is available online
at http://www.medicareappeal.com.

[71 FR 71303, 71312, and 71317 (Dec. 8, 2006)]
20.6 - Medicaid
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Information regarding the State Fair Hearing process can be obtained from the State
Administering Agency. States can determine whether the participant can bypass the
internal appeals process and go directly to the State Fair Hearing process.
The PACE organization must continue to furnish disputed services to Medicaid
participants until the appeal is complete.
If the decision is unfavorable to the participant, the participant would be responsible for
the cost of the disputed service.
The PACE organization must be sensitive to the State Fair Hearing time constraints to
ensure that the participant’s rights to access the State Fair Hearing are not negated by
failure to meet the State timeframes.
[42 § CFR 431.200 thru 431.250; 71 FR 71302 and 71304 (Dec. 8, 2006)]

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R2PACE 06/09/2011 	Initial Publication of Manual 	06/03/2011 NA
R1_SO 06/03/2011 	Initial Publication of Manual - Rescinded and
replaced by Transmittal 2
06/03/2011 NA
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