CMS Clarifies Provider Responsibilities When Patients Request Expedited Appeal of Medicare Service Terminations
Tuesday, June 4, 2013
by: VNAA Policy Team

Section: Public Policy and Advocacy




On May 24, the Centers for Medicare and Medicaid Services (CMS) released a claims manual update which specified four provider responsibilities for expedited review of Medicare service terminations. Changes to the manual go into effect August 26, 2013.

Beneficiaries have the right to appeal to a Quality Improvement Organization (QIO) when certain long-term care providers, including home health agencies and hospices, notify them that services will no longer be covered by Medicare. Under a final rule enacted in 2005, beneficiaries have a right to an expedited determination of these appeals. In an update to the Medicare Claims Processing manual, CMS provided detailed instructions regarding these expedited determinations, identifying the following four responsibilities for providers:
  • Deliver to the beneficiary a Detailed Explanation of Non-coverage (DENC) by close of business the day notification is received by a QIO;
  • Provide the QIO with copies of the DENC and the Notice of Medicare Non-Coverage (NOMNC) by the close of business on the day when notification of the expedited determination is received;
  • Furnish all requested information, including medical records requested by the QIO. This information can be submitted via phone, writing, or electronically. Keep written records of the transmittal if the information is shared via phone in the patient record; and
  • Provide the beneficiary, at their request, access to or copies of all documentation given to the QIO. These documents must be given to the beneficiary by the end of business on the first day after the material is requested.
The updates also include further details about who qualifies for an expedited determination, what should be included in the DENC and the NOMNC, and how documents should be delivered.

The manual also includes a hypothetical scenario calendar outlining the process for a resident who has been notified by a skilled nursing facility that Medicare-covered stay will end in 48 hours.

Click here to access the revised section of the manual.
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