CMS Pub. 100-11, ch. 11, § 20.4

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)]