being more appealing

Download Being More Appealing

Post on 22-Feb-2016




0 download

Embed Size (px)


Being More Appealing. Bobbi Buell ION October, 2008. AGENDA. Medicare Appeals Process The Appeal Cycle Assessment/ Analysis Information Gathering Appeal Drafting Follow Up Tools for Providers. PART A & PART B PROCESS (Non-Expedited). Beneficiary receives the service - PowerPoint PPT Presentation


  • Being More AppealingBobbi Buell IONOctober, 2008

  • AGENDAMedicare Appeals ProcessThe Appeal CycleAssessment/ AnalysisInformation GatheringAppeal DraftingFollow UpTools for Providers

  • PART A & PART B PROCESS (Non-Expedited)Beneficiary receives the service Medicare contractor (fiscal intermediary or carrier) issues initial determination explaining whether Medicare will pay for a service already received. Beneficiary has 120 days to request redetermination by contractor. Provider may also request redeterminationAppeals will be consolidatedTime frame may be extended for good causeContractor has 60 days to issue redetermination

  • PART A & PART B APPEALS (cont.)If redetermination is unfavorable can request areconsideration by Qualified IndependentContractors (QICs) 120 days to request reconsideration Beneficiary & provider appeals will be consolidated Time may be extended for good causeQIC must issue decision within 60 days. Parties may request escalation to ALJ if time frame not met60 days to request review by ALJ

  • ALJ HEARINGSHearings conducted by Medicare ALJs in DHHS Office of Medicare Hearings and AppealsALJs are in 4 regional offices, not local officesCleveland, OHIrvine, CAMiami, FLArlington, VAFor Part A and Part B claims, ALJ must issue decision within 90 days with exceptions No time limit if request for in-person hearing granted

  • ALJ HEARINGS (cont.)For ALJ hearings under Parts A, B, C & DAmount of claim must be at least $110 in 2007 Subject to annual increaseCan aggregate certain claimsHearings conducted by video teleconferencing (VTC) if available, or by telephone ALJ assigned to case has discretion to grant request for in-person hearing

  • APPEALS PROCESS BEYOND THE ALJ HEARINGIf ALJ decision is unfavorable, have 60 days to request MAC reviewMAC request requires specific statement of issues,MAC reviews the record concerning only those issues, unless unrepresented beneficiary requests. If MAC decision is unfavorable, have 60 days to request review in federal courtMust meet amount in controversy requirementAmount may increase each year ($1130 in 2007)

  • CALCULATING TIME FRAMESTime frames are generally calculated from date of receipt of notice5 days added to notice dateTime frames sometimes extended for good cause, ex.Serious illnessDeath in familyRecords destroyed by fire/flood, etcDid not receive noticeWrong information from contractorSent request in good faith but it did not arrive

  • MEDICARE ADVANTAGE APPEALSOrganization determination is initial determination regarding basic and optional benefitsCan be provided before or after services receivedIssued within 14 daysMay request expedited organization determination if delay could jeopardize life/health or ability to regain maximum function. Plan must treat as expedited if requested by doctorIssued within 72 hours


    Request reconsideration w/i 60 days of notice of the organization determination. Reconsideration decision issued within30 days for standard reconsideration. 72 hours for expedited reconsideration. Unfavorable reconsiderations automatically referred to independent review entity (IRE). Time frame for decision set by contract, not regulation Unfavorable IRE decisions may be appealed to ALJ to MAC to Federal Court


    Fast-Track Appeals to Independent Review Entity (IRE) before services end forTerminations of home health, SNF, CORFTwo-day advance noticeRequest review by noon of day after receive noticeIRE issues decision by noon of day after day it receives appeal request60 days to request reconsideration by IRE14 days for IRE to act

  • MEDICARE ADVANTAGE GRIEVANCE PROCEDURESGrievance procedures to address complaints that are not organization determinations. 60 after the event or incident to request grievanceDecision no later than 30 days of receipt of grievance. 24 hours for grievance concerning denial of request for expedited review.

  • PART D APPEALS PROCESS-OVERVIEWEach drug plan must have an appeals processIncluding process for expedited requestsA coverage determination is first step to get into the appeals process Issued by the drug plan An exception is a type of coverage determinationNext steps includeRedetermination by the drug planReconsideration by the independent review entity (IRE)Administrative law judge (ALJ) hearingMedicare Appeals Council (MAC) reviewFederal court

  • PART D APPEALS PROCESS COVERAGE DETERMINATIONA coverage determination may be requested byA beneficiary A beneficiarys appointed representativePrescribing physician Drug plan must issue coverage determination as expeditiously as enrollees health requires, but no later than 72 hours standard request Including when beneficiary already paid for drug 24 hours if expedited- standard time frame jeopardize life/health of beneficiary or ability to regain maximum function.

  • EXCEPTIONS: A SUBSET OF COVERAGE DETERMINATIONAn exception is a type of coverage determination and gets enrollee into the appeals process Beneficiaries may request an exceptionTo cover non-formulary drugsTo waive utilization management requirementsTo reduce cost sharing for formulary drugNo exception for specialty drugs or to reduce costs to tier for generic drugsA doctor must submit a statement in support of the exception

  • PART D APPEALS - COVERAGE DETERMINATIONS ARE NOT AUTOMATICA statement by the pharmacy (not by the Plan) that the Plan will not cover a requested drug is not a coverage determinationEnrollee who wants to appeal must contact drug plan to get a coverage determinationDrug plan must arrange with network pharmaciesTo post generic notice telling enrollees to contact plan if they disagree with information provided by pharmacist orTo distribute generic notice

  • PART D APPEALS PROCESS NEXT STEPSIf a coverage determination is unfavorable:Redetermination by the drug plan. Beneficiary has 60 days to file written request (plan may accept oral requests). Plan must act within 7 days - standardPlan must act within 72 hrs.- expeditedThen, Reconsideration by IREBeneficiary has 60 days to file written requestIRE must act w/i 7 days standard, 72 hrs. expeditedALJ hearingMAC reviewFederal court

  • PART D GRIEVANCE PROCESSEach drug plan must have a separate grievance process to address issues that are not appealsMay be filed orally /in writing w/i 60 daysPlans must resolve grievancesw/i 30 days generallyw/i 24 hrs if arise from decision not to expedite coverage determination or redetermination



  • Intro Topic, On-going Project

    Presenters VG & PN Sr Policy Attys / DCJAS / CT

    Much info NOT all slides A FEW edits since sent to MS

    Q & A at end to be efficient with time so keep notes of Qs Not: Until then you are on MUTE We cant hear you