Managed Care Appeals
Medicare+Choice enrollees now have the right to an expedited review by Primaris when they disagree with their plan's decision that coverage of their services from a skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF) should end. This new right originates from the Grijalva v Shalala class action lawsuit, and is similar to the longstanding right of a Medicare beneficiary to request a QIO review of an inpatient hospital discharge.
Based on the April 2003 final rule (42 CFR Parts 422 and 489), Medicare+Choice must provide an advance notice of Medicare coverage termination to Medicare+Choice enrollees no later than two days (two visits in the case of home health services) before coverage ends. If the patient does not agree that covered services should end, they may request a Fast Track review by Primaris. Their Medicare+Choice plan must furnish a detailed explanation for why services are no longer necessary or covered. The review process will generally be completed within 48 hours of the enrollee's request.
The new SNF, HHA and CORF notification and appeal requirements distribute responsibilities between four parties:
- The Medicare+Choice plan determines the termination date and provides (upon request) a detailed explanation of termination. The plan must also provide Primaris with required information (medical records) to complete an appeal review. Medicare+Choice plans may choose to delegate these responsibilities to their contracting providers.
- The provider delivers the Notice of Medicare Non-Coverage (NOMNC), upon direction from the plan, to enrollees no later than two days or two visits before their covered services end.
- The Medicare+Choice enrollee or authorized representative acknowledges receipt of the notice and contacts Primaris (within the specified timeframe) for an expedited review.
- Primaris will immediately contact the Medicare+Choice organization and the provider when an expedited review is requested. They will also process the appeal and make a decision within one day after receiving all the necessary information. Primaris must be available to receive and process appeals during normal business hours, seven days per week, including weekends and holidays.
These new procedures went into effect on January 1, 2004. Also be aware that the Medicare law establishes similar rights for “fee-for-service” beneficiaries in these same settings (HHA, SNF and CORF). For now, the process for traditional Medicare beneficiaries in these settings has not changed, but procedures similar to the new Fast Track process are expected soon. Providers should continue to use either the Home Health Advanced Beneficiary Notice (HHABN) or Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) until these changes are announced. The issuance and appeal process for Notices of Non-Coverage (HINNs and NODMARS) in the acute setting have not changed.
Primaris encourages providers to work with Medicare+Choice plans to establish processes for issuing these notices in an appropriate and timely manner. A provider does not have to agree with the decision that covered services should end, but must still carry out this function under its Medicare provider agreement. For more information contact Rita Ketterlin at (800) 735-6776, Ext. 153 or email rketterlin@primaris.org.
Helpful Information
For further information about individual case review, please contact Lori Schieferdecker, Medicare Beneficiary Protection Program, at (800) 735-6776, Ext 155.
If you are a provider wanting information, call Missouri's provider helpline at (800) 735-6776.
If you are a Medicare beneficiary, or are representing a beneficiary, call our beneficiary help line at (800) 347-1016.