Medicare Appeals: Provider Information About Fee for Service
Effective July 1, 2005, new requirements under the Benefits Improvement and Protection Act (BIPA) allow Medicare fee-for-service beneficiaries to request an appeal upon notification of discharge or termination of
services at a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, or skilled nursing facility (SNF). CORFs, HHAs, hospices, and SNFs will be required to issue Medicare fee-for-service beneficiaries a notice of Medicare provider non-coverage (Generic Notice) that informs the beneficiary of the date that coverage of services is going to end and describes what should be done if the beneficiary wants the discharge decision to be reviewed.
The CORF, HHA, hospice, or SNF is responsible for delivering the Generic Notice no later than two days before the covered services will end. If there is more than a two-day span between services (e.g., in the home health setting), the Generic Notice should be issued the next-to-last time services are furnished. The notice must explain to beneficiaries their rights to the new appeal process regarding their impending discharge or termination of services. A "valid" notice must be delivered correctly to the beneficiary or authorized representative. The notice must have the correct patient-specific information and the date that coverage of services ends, and it must identify the appropriate QIO and appeal rights. Health Services Advisory Group (HSAG) is the QIO for the state of Arizona.
In order to qualify for an expedited appeal, the beneficiary must contact HSAG to request an appeal no later than noon on the day before services are to end if he/she disagrees with the notice. When a beneficiary requests an appeal, HSAG will notify the provider of the appeal request. The provider is responsible for providing the beneficiary and the QIO with a patient-specific Detailed Notice that gives a detailed explanation of why coverage is ending. The provider will have to furnish, within a strictly limited time frame, the medical records requested and the Generic and Detailed Notice to HSAG for the review process. Based on the time frames associated with the expedited review process, HSAG’s decision should take place 72 hours after receipt of the beneficiary's request for a review. The beneficiary or his/her authorized representative, the provider, and the physician are notified of HSAG's determination.
The links below will open new windows:
If you have any questions, please call 1-800-359-9909 or contact Suzanne Powell at 602-801-6902.
<
TOP>