MEDICARE ADVANTAGE

General Information

Medicare Advantage plans are managed care plans that contract with Medicare to offer all Medicare covered services plus additional services outside of traditional Medicare (e.g. vision coverage or prescription drug coverage).

Medicare Advantage plans are required to follow all Medicare laws and coverage policies, including LCDs (Local Coverage Decisions - coverage policies set by Medicare Fee-for-Service Contractors in your geographic area), when determining coverage for a particular service. Select "Laws and Regulations" to find helpful links to Medicare laws and other CMS coverage policies.

Select "CMS web site" (below) to find useful industry and program information. Select CMS Medicare Managed Care Manual for CMS program and policy guidance to Medicare Advantage plans.

Please see Newsletters & Best Practices page for helpful information on appeal case file preparation and processing.

Appeal Information

Medicare Advantage plans are required to submit all denied enrollee appeals (Reconsiderations) to an Independent Review Entity (MAXIMUS Federal Services). Medicare Advantage plans should carefully review and follow the instructions in the "MAXIMUS Federal Services Reconsideration Process Manual for Medicare Advantage Organizations."

The "MAXIMUS Federal Services Reconsideration Process Manual for Medicare Advantage Organizations (updated 10/2015)" contains required forms for creating and submitting a case to MAXIMUS Federal Services. Select "Medicare Advantage Forms" to download these forms and the relevant instructions.

MAXIMUS Federal Services Reconsideration Process Manual for Medicare Advantage Organizations (updated 10/2015)

Reconsideration Background Data Form (PDF)

Reconsideration Background Data Form (MS-Word Document)

Medicare Managed Care Dismissal Case File Data Form (PDF)

Medicare Managed Care Dismissal Case File Data Form (MS-Word Document)

Key Contact Form

CMS Web site

CMS Medicare Managed Care Manual

Navigating the CMS Online Manual System (explanatory brochure)

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