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Classifying An Enrollee Billing Complaint as a Grievance, Coverage Request, or Both?

When an enrollee contacts the plan about a provider’s bill, it can be challenging to determine if the enrollee’s issue should be classified as an inquiry or processed under the organization determination, reconsideration, grievance, or combination of more than one procedure. This article uses a real-life scenario to demonstrate the critical thinking skills that must be employed to properly classify the request to ensure timely resolution under the correct procedure(s).


On 8/15/2023 an enrollee writes to the plan asserting a provider continues to bill $50.25 for a 6/1/2023 date of service, despite the enrollee previously advising the claim had been paid in full. In addition to the bill dated 8/1/2023 and a written narrative, the enrollee includes evidence of $335 paid to the provider on 6/1/2023. The enrollee provides details of an attempt to resolve the issue directly with the provider’s office, asking to have billing stopped and to be refunded $104 that was overpaid at the time the service was rendered. The enrollee’s narrative describes a dissatisfying experience with the office staff who became irate, refused to refund any amount, and stated that if the bill is not paid in the next 15 days it will go to collections.

There are three issues in the enrollee communication:

  1. Continued “improper” provider billing,
  2. Failure to provide the requested $104 refund, and
  3. Staff behavior in response to request for refund.

Classifying the Issues

Issues 1 and 3 should be processed under the grievance procedures. Research is required to determine if issue 2 should be processed as an organization determination or reconsideration.


Upon review it is determined a claim was processed and approved in whole for the 6/1/2023 date of service. The plan allowed $335 of the billed $385.25 charge, based on the applicable fee schedule, and the plan paid $104 and assigned $231 to enrollee cost share. Because the enrollee is not disputing the cost share assigned by the plan and there is no record of a previous request for reimbursement, issue 2 should be processed as an organization determination, member request for reimbursement.

If the enrollee had called member services and communicated the same issues, how the plan classifies issue 2 would depend on whether the plan accepts verbal payment requests from enrollees. If the plan does not, then all issues could be processed under the grievance procedure and the grievance resolution should include an explanation of how a written request for reimbursement can be made to the plan. If the plan does accept verbal request for payment from enrollees, then issue 2 should be processed under the organization determination procedures and not the grievance procedures. BluePeak has experienced plans that accept verbal payment requests processing enrollee complaints regarding overpayments via the grievance procedure and looking to the provider to reimburse the enrollee. The challenge in delegating the reimbursement to the provider is the grievance must be fully resolved in 30 calendar days, 44 if an extension is taken, and to be fully resolved the plan must confirm the enrollee has received the reimbursement due from the provider. If the plan resolves the grievance without confirming the enrollee has been reimbursed the plan can be found non-compliant for not fully investigating and/or taking actions to appropriately address all issues raised in grievances (not to mention, there may be subsequent grievances from the enrollee regarding the reimbursement). If the plan leaves the grievance open until fully resolved but cannot confirm reimbursement within the timeframe allowed to resolve the grievance the plan can be found non-compliant for failing to notify the enrollee of resolution of standard grievances within CMS timeframes.

However, if the plan processes the request as an organization determination, the plan has 60 calendar days to reimburse the enrollee or provide notification of its decision to deny the request, including appeal rights. During these 60 days, the plan can develop the claim including outreach to the provider to request they reimburse the enrollee directly, if applicable. If the plan determines the provider will not reimburse the member, the plan can reimburse the enrollee within 60 days and recoup the funds from the provider in accordance with its procedures.

CMS provided Lessons Learned for Sponsors in the 2022 Part C and Part D Program Audit and Enforcement Report published July 18, 2023. In this section CMS calls out the plan’s responsibility to ensure enrollees are refunded all amounts incorrectly collected either directly or through delegation to the provider. CMS also provides its expectation the plan conduct outreach to the provider to confirm the enrollee has been reimbursed when reimbursement is delegated. Directing the provider to refund the enrollee is not sufficient in and of itself.

Processing claims with incorrect cost share amounts or allowing enrollees to be charged more than applicable cost share by providers poses a risk to Medicare Advantage Organizations (MAOs) in financial and program audits. BluePeak can provide claims assessments to identify any risk of improper configuration to the approved benefit package as well as analyze enrollee communications to identify trends indicative of incorrect claims processing to help your plan mitigate risk of non-compliance and enforcement actions.

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