An MA organization, with respect to each MA plan that it offers, must establish and maintain:
- A grievance procedure for addressing issues that do not involve organization determinations
- A procedure for making timely organization determinations
- Appeal procedures for issues that involve organization determinations
If the MA organization delegates any of its appeal or grievance responsibilities to another entity or individual through which the organization provides health care services, the MA organization is ultimately responsible for ensuring that the entity or individual satisfies the relevant requirements.
Note: All providers must adhere to the Peoples Health appeals and grievances policies and procedures.