FROM: Theodore O. Will, Chief Executive Officer
DATE: Dec 07, 2004
SUBJECT: MEDICARE ADVANTAGE - "FAST TRACK" APPEAL PROCESS UPDATE
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
As you are aware, IPRO, as the Quality Improvement Organization (QIO) for New York State conducts "fast track" appeals for service terminations issued to Medicare Advantage (MA) Plan enrollees in the Home Care (HC), Comprehensive Outpatient Rehabilitation Facility (CORF) and Nursing Facility (NF) Settings. In follow-up to a recent discussion, IPRO is providing clarification in regard to some operational issues that impact the "Fast Track" appeal process. Please note, there has been no change in the appeal process, itself.
It is suggested that the MA Plan and/or Provider call IPRO at 1-888-696-9561 when they are faxing information to us or, if they should experience any difficulty with faxing so that the problem can be resolved. In addition, please feel free to use this telephone number should you have any questions related to the Fast Track Appeal process. If we are unable to take your call, voicemail is available, so that the caller can leave a message with his/her name, phone number. IPRO staff will return the call during our regular business hours, as noted above.
In some instances, when an Enrollee/Representative calls IPRO to request a Fast Track Appeal, it is not clear if the caller has missed the deadline to file a QIO appeal. In those instances, IPRO will request the notice of non-coverage from the MA Plan to verify if the deadline was missed. If missed, the caller will then be referred to their Plan to pursue the appeal, as per the established MA appeals process.
Should additional information be needed to conduct the review, IPRO will call the MA Plan to request the information and will also fax a written copy of our request.
To facilitate ongoing process improvement, we would appreciate it if you would share this Memorandum with your panel of HC, CORF and NF providers throughout New York State.
Should you have any questions or require further clarification, 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.