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Beneficiaries in traditional Medicare can access a fast-track, expedited review process when Medicare coverage of their comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, or skilled nursing facility (SNF) services are about to end. The requirement for these expedited reviews, which began on July 1, 2005, stems from section 1869(b)(1)(F) of the Social Security Act (the Act), as amended by section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106--554. The Centers for Medicare & Medicaid Services (CMS) published the final regulations needed to implement the new process on November 26, 2004 (69 FR 69252). As a result of these regulations, the review process for Medicare beneficiaries in traditional Medicare will essentially parallel the expedited review process that has been in effect for Medicare managed-care enrollees since January 1, 2004. Based on the provisions of the November 2004 final rule, CORFs, HHAs, hospices, and SNFs must provide the notice of Medicare provider non-coverage (Generic Notice) to Medicare beneficiaries no later than two days before the effective date that coverage of their Medicare services will end. If the beneficiary does not agree that coverage should end, the beneficiary may request an expedited review of the termination decision by the Quality Improvement Organization (QIO) in that state. Colorado Foundation for Medical Care (CFMC) is the QIO for the state of Colorado. The provider then must furnish the detailed explanation of non-coverage (Detailed Notice) to the beneficiary explaining why services are no longer covered. Generally, CFMC’s review will be completed within 72 hours of receipt of the beneficiary's request for a review. The links below open new windows:
The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
do not necessarily reflect CMS Policy. |
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