Medicare Appeals: Provider Information About
Fee for Service

Requirements under the Benefits Improvement and Protection Act (BIPA) allow Medicare fee-for-service beneficiaries to request an appeal upon notification of discharge or termination of services at a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, or skilled nursing facility (SNF). CORFs, HHAs, hospices, and SNFs will be required to issue Medicare fee-for-service beneficiaries a notice of Medicare provider non-coverage (Generic Notice) that informs the beneficiary of the date that coverage of services is going to end, and describes what should be done if the beneficiary wants the decision to be reviewed.

The CORF, HHA, hospice, or SNF is responsible for delivering the Generic Notice no later than two days before the covered services will end. If there is more than a two day span between services (e.g. in the home health setting) the Generic Notice should be issued the next to last time services are furnished. The notice must explain to beneficiaries their rights to the new appeal process regarding their impending discharge or termination of services. A "valid" notice must be delivered correctly to the beneficiary or authorized representative. The notice must have the correct patient-specific information, the date that coverage of services ends, and identifies the appropriate QIO and appeal rights. The Colorado Foundation for Medical Care is the QIO for the state of Colorado (CFMC).

In order to qualify for an expedited review, the beneficiary must contact CFMC to request an appeal no later than noon on the day before services are to end if he/she disagrees with the notice. When a beneficiary requests an appeal, CFMC will notify the provider of the appeal request. The provider is responsible for providing a Detailed Notice to the beneficiary and the QIO that is patient specific, and provides a detailed explanation of why coverage is ending. The provider will have to furnish, within a strictly limited time frame, the medical records requested and the Generic and Detailed Notice to CFMC for the review process. Based on the timeframes associated with the expedited review process, CFMC’s decision should take place 72 hours after receipt of the beneficiary's request for a review. The beneficiary or his/her authorized representative, the provider, and the physician are notified of CFMC's determination.

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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.

Medicare Appeals: Provider Information About Fee for Service

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Medicare Appeals: Provider Information About
Fee for Service