Administrative Memos

200301

FROM: Theodore O. Will, Chief Executive Officer
DATE: Dec 05, 2003
SUBJECT: QIO Review of Medicare + Choice Enrollee Appeals of Termination of Coverage in Multiple Settings
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364
Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423

As you may already be aware, effective January 1, 2004, IPRO, the Quality Improvement Organization (QIO) for New York, will begin to review Medicare Plus Choice (M+CO) enrollee requests for "fast track appeals" should they receive a M+CO denial for coverage of services being provided in the Homecare, Nursing Facility or Comprehensive Outpatient Rehabilitation Facility (CORF) setting.

The "fast track appeal" process requires that the enrollee or enrollee's representative contact IPRO by noon of the day following receipt of the notice to request an appeal. IPRO will receive these appeals seven days a week (including weekends and holidays) during business hours (8:30AM to 4:30PM). IPRO must then contact the M+CO (at the time of the appeal) in order to request medical records and any other required information.

To facilitate this appeal process, IPRO is requesting contact information for your organization. Please complete the "Fax-Back Form" and return it to the attention of Lori DeRise no later than December 19, 2003.

IPRO
1979 Marcus Avenue
Lake Success, N.Y. 11042-1002
IPRO Fax # 516-326-6176

In addition, please designate an IPRO Liaison who will serve as the point person within your M+CO responsible for receiving and disseminating all future written correspondence, administrative memoranda, program directives, etc. from IPRO in regard to the appeals process.

Should you have any questions or require additional information, please do not hesitate to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364 or Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423.