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When a Medicare health plan terminates coverage of an inpatient hospital admission, or when pre-authorized services, either directly or by delegation, are terminated in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), a special expedited review procedure applies. Appeals filed timely bypass the health plan's reconsideration process, and an independent review entity known as a Quality Improvement Organization (QIO) performs a specialized expedited review. To get the name and phone number of the QIO for your state, check your provider termination notice or call 1-800-MEDICARE. For detailed guidance on the Medicare health plan and inpatient hospital appeals processes, click on Chapter 13 of the Medicare Managed Care Manual - Beneficiary Grievances, Organization Determinations, and Appeals, in the "Related Links Inside CMS" section below, and the "Notices and Forms" link on left side of this page. QIO Review of SNF, HHA or CORF Terminations In the case of SNF, HHA or CORF services, providers must issue a termination notice to the enrollee at least two calendar days prior to the end of the services. This notice is titled the "Notice of Medicare Non-Coverage" (NOMNC). When a provider issues a NOMNC, the enrollee may appeal (request review of) the termination to a QIO. An enrollee or an enrollee's representative may request an expedited QIO review of a termination of SNF, HHA or CORF services. The request for review must be filed with the QIO no later than noon of the day before termination of services. The enrollee should call the QIO listed on the termination notice. You may view a copy of the NOMNC by clicking on the link to the Notices and Forms page (see navigation tool on the left side of this page to link to the Notice and Forms page). If an appeal is filed, the enrollee will receive from the health plan a Detailed Explanation of Non-Coverage (DENC) that gives the reasons why the health plan made the decision to terminate services. A copy of this form may be viewed by clicking on the link section below. For more information about provider terminations and QIO appeals, see section 90.2 to 90.10 in Chapter 13 of the Medicare Managed Care Manual – Beneficiary Grievances, Organization Determinations, and Appeals in the "Related Links Inside CMS" section below. For more information about appointing a representative, see section 60.1.1 in Chapter 13 of the Medicare Managed Care Manual – Beneficiary Grievances, Organization Determinations, and Appeals in the "Related Links Inside CMS" section below. How the QIO Processes Appeal Requests in SNF, HHA or CORF services Once the appeal request is received by the QIO, the QIO must notify the enrollee of its decision as quickly as the enrollee's health requires, but no later than close of business of the day after receiving all of the information it needs to make its determination. If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a hearing with an Administrative Law Judge (ALJ). - Use the navigation tool on the left side of this page to link to subpages that contain detailed information about hearings with an ALJ or any other level of appeal.
How Late Requests Are Handled If the deadline for requesting QIO Review is missed, the enrollee or his or her representative may still ask the health plan for an expedited appeal. The plan will review the decision under its rules for standard appeals if the request does not meet the criteria for an expedited review. For more information, please see Sections 80 – 80.4 of Chapter 13 of the Medicare Managed Care Manual in the "Related Links Inside CMS" section below, the plan's Evidence of Coverage, or contact the plan or 1-800-MEDICARE.
Page Last Modified: 09/10/2008 12:30:54 PM
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