Welcome to The Billers' Association For Long-Term Care

The Billers’ Association for Long-Term Care (BALTC) is a membership community created specifically for professionals involved in the long-term care revenue cycle. This national association provides members with a resource of continuously updated tools, reimbursement and regulatory guidance, and education to help prevent revenue loss and documentation and billing errors so providers can withstand audits at any point in time. With its involved expert advisory board members and active talk group, this engaged group of professionals is a great place for sharing and receiving best practices, tips, and tools with your peers.

Learn More Join

Medicare managed care appeals and grievances

Jul 06, 2017
The Bottom Line

Medicare health plans, which include Medicare Advantage (MA) plans – such as Health Maintenance Organizations, Preferred Provider Organizations, Medical Savings Account plans and Private Fee-For-Service plans – Cost Plans and Health Care Prepayment Plans, must meet the requirements for grievance and appeals processing under Subpart M of the Medicare Advantage regulations.  For a detailed discussion of the Medicare managed care grievance and appeals processes, click here.

Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights. If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination.  Additionally, Medicare health plan enrollees receiving covered services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast, or expedited, review if they think their Medicare-covered services are ending too soon. 

Free Resources

Access sample white papers, tools, analysis, and resources.