§ 422.125 - Resolution of complaints in a Complaints Tracking Module.

§ 422.125 xxx

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Resolution of complaints in a Complaints Tracking Module.

(a) Definitions. For the purposes of this section, the terms have the following meanings:

Assignment date is the date CMS assigns a complaint to a particular MA organization in the Complaints Tracking Module.

Complaints Tracking Module means an electronic system maintained by CMS to record and track complaints submitted to CMS about Medicare health and drug plans from beneficiaries and others.

Immediate need complaint means a complaint involving a situation that prevents a beneficiary from accessing care or a service for which they have an immediate need. This includes when the beneficiary currently has enough of the drug or supply to which they are seeking access to last for 2 or fewer days.

Urgent complaint means a complaint involving a situation that prevents a beneficiary from accessing care or a service for which they do not have an immediate need. This includes when the beneficiary currently has enough of the drug or supply to which they are seeking access to last for 3 to 14 days.

(b) Timelines for complaint resolution —

(1) Immediate need complaints. The MA organization must resolve immediate need complaints within 2 calendar days of the assignment date.

(2) Urgent complaints. The MA organization must resolve urgent complaints within 7 calendar days of the assignment date.

(3) All other complaints. The MA organization must resolve all other complaints within 30 calendar days of the assignment date.

(4) Extensions. Except for immediate need complaints, urgent complaints, and any complaint that requires expedited treatment under §§ 422.564(f) or 422.630(d), if a complaint is also a grievance within the scope of §§ 422.564 or 422.630 and the requirements for an extension of the time to provide a response in §§ 422.564(e)(2) or 422.630(e)(2) are met, the MA organization may extend the timeline to provide a response.

(5) Coordination with timeframes for grievances, PACE service determination requests, and PACE appeals. When a complaint under this section is also a grievance within the scope of §§ 422.564, 422.630, or 460.120, a PACE service determination request within the scope of § 460.121, or a PACE appeal within the definition of § 460.122, the MA organization must comply with the shortest applicable timeframe for resolution of the complaint.

(c) Timeline for contacting individual filing a complaint.: Regardless of the type of complaint received, the MA organization must attempt to contact the individual who filed a complaint within 7 calendar days of the assignment date.

[89 FR 30820, Apr. 23, 2024

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