Our
contracted providers share responsibility in the Medicare Advantage
(MA) fast-track appeals process for skilled nursing facility (SNF),
home health agency (HHA) and comprehensive outpatient rehabilitation
facility (CORF) discharges. The Centers for Medicare & Medicaid
Services (CMS) has incorporated the fast-track appeals requirements
into the CMS Monitoring Guide, and will conduct reviews to help ensure
adherence with the requirements. Available here is background information
on this member appeals process, as well as related documents that
outline the requirements. Please read and understand this important
information.
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Since
January 1, 2004, MA plan enrollees have had the right to a fast-track
appeals process when they disagree with the discontinuation of SNF,
HHA or CORF care services. This appeals process requires that eligible
members receive a copy of the Notice of Medicare Non-Coverage (NOMNC)
“The Advance Notice” CMS-10095. The
regulations state that providers must issue this required notice to
enrollees prior to the termination of SNF, HHA or CORF services.
In addition, when an MA plan enrollee initiates a fast-track appeals
review, MAO is required to immediately provide a detailed notice of
denial to the enrollee and the Quality Improvement Organization (QIO)
that is reviewing the enrollee’s appeal. The QIO is also provided
with copies of supporting medical documentation to assist in making
a determination.
A Quick Reference Guide outlining
the requirements is included here to help ensure that you and your
staff are aware of the CMS requirement and are implementing any necessary
internal process changes.
Fast
Track Quick Reference Guide (.pdf)
Thank you for your participation in our Medicare Advantage plans and
cooperation with this regulatory requirement.
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