Medicare Appeals: Provider Information About
Medicare Advantage

Members of Medicare Advantage (MA) plans have the right to an expedited (fast track) review by a Medicare quality improvement organization (QIO) when they disagree with their MA plan's decision that Medicare coverage of their services from a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or skilled nursing facility (SNF) should end. Expedited reviews became effective January 1, 2004. The Colorado Foundation for Medical Care (CFMC) is the QIO for the state of Colorado.

Based on the provisions of the April 2003 Grijalva v. Shalala ruling, CORFs, HHAs, and SNFs must provide an advance notice of Medicare coverage termination to MA beneficiaries no later than two days before coverage of their services will end. If the beneficiary does not agree that covered services should end, the beneficiary may request an expedited review of the case by CFMC.

The request for an appeal must be made by noon on the day prior to the effective date. After a valid appeal request is received, the MA organization and the provider are notified of the appeal request by CFMC. The beneficiary's MA plan must furnish a detailed notice to the beneficiary explaining why services are no longer necessary or covered. The provider must furnish the requested medical records and a copy of both the advanced and detailed notice to CFMC within a limited timeframe. The review process generally will be completed within two days of the beneficiary's request for a review. The overall intent of the fast-track appeal is to limit the beneficiary's financial liability. Once CFMC makes its review determination, the beneficiary or his/her authorized representative, the provider, and the MA organization are informed of the results.

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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 Medicare Advantage

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Medicare Appeals: Provider Information About
Medicare Advantage