Appeals, Grievances, and Determinations

This is an especially critical and—given CMS’ focus on beneficiary protections—high-profile area of your compliance program. Gorman Health Group can help your organization restructure and improve your internal processes for meeting A, G, & D requirements, including providing staff training, conducting gap analyses, and providing access to GHG’s ready-to-use database that will help you rapidly move through any backlog of issues, while organizing your efforts to respond to member issues and generate the CMS universes at the push of a button.

A, G, & D Components:

• Staff training in correctly identifying Coverage Determinations (CD) or Organization Determinations (OD), Appeals, Grievances, and Inquiries
• Staff training in correctly processing CD/ODs, appeals and grievances.
• Access to GHG’s ready-to-use database that tracks appeals and grievances, calculates due dates, and generates reports and universes.
• Assistance in identifying crucial elements for developing or enhancing plan tracking systems (Our OMT is one option for a track system.)
• Assistance updating plan policies and procedures to comply with CMS requirements.
• Targeted audits, case reviews or gap analysis to help plans identify problem areas.

• Follow-up support.

For additional information, please call (202) 364-8283 today.