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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 Elaine Nelson at 602-745-6219.
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Health Services Advisory Group (HSAG), the Medicare Quality Improvement Organization
for Arizona, prepared this material under contract with the Centers for Medicare
& Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents do not necessarily reflect CMS policy.
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