1. Dual Eligibles
Grievances & Appeals

2. Grievances Medicaid

3. Grievances Medicare

4. Summary: Providers What You Need To Know
Medicare
Medicaid
Grievances can originate at the Provider level or at the Authority
Grievances can originate at the Provider Level, MCPN or at the Authority
Enrollees only have 60 days of an occurrence to file a grievance
There is no time limit for filing a grievance
Resolution of grievance is not to exceed 30 days
Resolution of grievance is not to exceed 60 days
Acknowledgement of grievance is required within 3 days of receipt
Acknowledgement of grievance is required within 5 days of receipt
Enrollee may have an appointed representative to act on his/her behalf. Must have an Appointment of Representative (AOR) form on file.
Grievances can be filed by the enrollee or a legal representative; no specific form required as long as there is supporting documentation
If enrollee is not in agreement with the findings of the grievance, he/she may request a review by Independent Review Entity (IRE) in 10 days of resolution
If resolution of grievance is not completed within 60 days, an enrollee may request a Medicaid Fair Hearing

6. Appeals Medicare

7. Appeals Medicare - Continued

8. Summary: Providers What You Need to Know
Effective March 1, 2015 all Appeals were brought in house and are handled by Customer Service’s DWMHA Appeals Coordinator for resolution and disposition.
An Action that has resulted in an Appeal will require that providers generate within 24 hours all supporting documentation to DWMHA’s Appeals Coordinator for follow- up.
The correct Action Notice form (Medicaid vs Medicare) needs to be generated by the Provider. Note a service may require both forms.
Forms and Policies will be made available to all providers shortly.
It is the provider’s responsibility to educate enrollees on their due process rights.
React quickly to a problem, your efforts may often eliminate the need for an Appeal.
Medicaid Appeals allow for 45 calendar days to resolve vs. Medicare which allows 30 days
We will need you to provide a summary of all you dual eligible appeals to monthly

9. Important Contacts GRIEVANCES APPEALS India Crockett 313-833-7141
Pamela Oehmke

10. Q&A