CMS Pub. 100-11, ch. 11, § 20

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)]