FROM: Theodore O. Will, Chief Executive Officer
DATE: Jan 06, 2004
SUBJECT: Clarification - Medicare+Choice Appeal and Grievance Procedure and "New Advance Notice"
IPRO CONTACTS:
Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423 or Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364
IPRO has received the following clarification from the Centers for Medicare/Medicaid Services (CMS) in regard to the new Medicare+Choice Appeals and Grievance Procedures implemented January 1, 2004.
The clarification is in regard to the requirement at 422.626(a)(1) which states that "An enrollee who desires a fast-track appeal must submit a request for an appeal to an IRE under contract with CMS, in writing or by telephone, by noon of the first day after the day of delivery of the termination notice." It has been determined by the Centers for Beneficiary Choices in consultation with the Office of General Counsel of CMS to mean that while the enrollee may receive an advance notice 4-5 days prior to the termination date, the enrollee would technically have until noon of the day before the termination date to request an appeal. Please refer to the Q & A below for clarification:
Q. If an enrollee receives a Notice of Medicare Non-Coverage (NOMNC) sooner than two days prior to the effective date that Medicare coverage ends, is the enrollee required to request an appeal by noon of the day following receipt on the NOMNC?
A. No. Although 42 CFR 422.626(a)(1) requires an enrollee to submit a request for an appeal by noon of the first day after receipt of the NOMNC, this deadline is premised on the NOMNC being delivered on the last permissible day. If the notice is delivered earlier, the enrollee's request is still considered timely as long as the QIO receives the appeal request no later than noon the day before the effective date that Medicare coverage ends. Enrollees are encouraged to request an appeal as early as possible to facilitate timely QIO reviews and minimize potential liability. The enrollee is entitled to the maximum amount of time needed to decide whether services continue to be medically necessary, i.e., the day before Medicare covered services are scheduled to end.
In addition, we have been provided a copy of the attached "new advance notice" as well as directions for its use. This form, CMS-10095-A, may also be downloaded from the CMS website http://cms.hhs.gov/medicare/bni.
Should you have any questions in regard to this memorandum, please feel free to contact Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423 or Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364.
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