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). Medicare Advantage plans should carefully review and follow the instructions in the "Maximus Reconsideration Process Manual for Medicare Advantage Organizations."
The "Maximus Reconsideration Process Manual for Medicare Advantage Organizations (updated 09/24)" contains required forms for creating and submitting a case to Maximus. Select "Medicare Advantage Forms" to download these forms and the relevant instructions.
Maximus Reconsideration Process Manual for Medicare Advantage Organizations (updated 09/24)
Reconsideration Background Data Form (PDF)
Medicare Managed Care Dismissal Case File Data Form (PDF)
CMS Medicare Managed Care Manual
Navigating the CMS Online Manual System (explanatory brochure)