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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.
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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