CMS: Four provider responsibilities when residents want an expedited appeal of Medicare service terminations

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The Centers for Medicare & Medicaid Services specified four provider responsibilities for expedited review of Medicare service terminations in a recent claims manual update.

Beneficiaries can appeal to a Quality Improvement Organization when certain long-term care providers, including skilled nursing facilities 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 a May 24 update to the Medicare Claims Processing manual, CMS provided detailed instructions regarding these expedited determinations, identifying the following four responsibilities for providers:

  • Deliver a Detailed Explanation of Non-coverage (DENC) to the beneficiary within 24 hours of being notified by a QIO of the request for expedited determination.
  • Provide the QIO with the DENC and the Notice of Medicare Non-Coverage (NOMNC) by end of business on the day when notification of the expedited determination is received.
  • Furnish all requested information, including medical records, to the QIO, keeping written records of the transmittal if the information is shared via phone.
  • Provide the beneficiary access to all documentation given to the QIO upon request. These documents must be transmitted to the beneficiary by the end of business on the first day after the material is requested.

The 18-page manual update includes further details about who qualifies for an expedited determination, what should be included in the DENC and the NOMNC, and how deliveries of documents should be made.

It also includes a calendar showing how the process would work in a hypothetical situation, for a resident who has been notified by a SNF that his Medicare-covered stay will end in 48 hours.

The changes to the manual are effective August 26.

Click here to access the revised section of the manual.