Medicare Appeals: Provider Information About Medicare Advantage (Medicare Health plan)
Effective January 1, 2004, members of Medicare Advantage (MA) plans have the right to an expedited (fast-track) review by a Medicare Quality Improvement Organization (QIO) when they disagree with their MA plan's decision that Medicare coverage of their services from a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or skilled nursing facility (SNF) should end
. Health Services Advisory Group (HSAG) is the QIO for the state of Arizona.
Based on the provisions of the April 2003 Grijalva v. Shalala ruling, CORFs, HHAs, and SNFs must provide an Advance Notice of Medicare coverage termination to MA beneficiaries no later than two days before coverage of their services will end. If the beneficiary does not agree that covered services should end, the beneficiary may request an expedited review of the case by HSAG.
The request for an appeal must be made by noon on the day prior to the effective date. After a valid appeal request is received, the Medicare Health plan organization and the provider are notified of the appeal request by HSAG. The beneficiary's Medicare Health plan must furnish a Detailed Notice to the beneficiary explaining why services are no longer necessary or covered. The provider must furnish the requested medical records and a copy of both the Advanced and Detailed Notice to HSAG within a limited time frame. The review process generally will be completed within two days of the beneficiary's request for a review. The overall intent of the fast-track appeal is to limit the beneficiary's financial liability. Once HSAG makes its review determination, the beneficiary or his/her authorized representative, the provider, and the Medicare Health plan organization are informed of the results.
CMS is issuing a new combined Notice of Medicare Non-Coverage. This notice will replace the CMS 10095 (Medicare Advantage notice) and the CMS 10123 (Original Medicare notice). This combined notice retains the form number of the current Original Medicare Notice (CMS 10123) and the name of the MA notice (Notice of Medicare Non-Coverage, or NOMNC). CMS also is issuing a new Detailed Explanation of Non-Coverage, or DENC, with the form number CMS 10124.
The new, combined notices must be in use as soon as possible, but no later than May 1, 2012.