Benefits Improvement and Protection Act
Expedited Appeal Review for Termination of Fee-For-Service Medicare Coverage
On July 1, 2005, new Medicare regulations (the Benefits Improvement and Protection Act) will give beneficiaries access to a new expedited determination process when their Medicare-covered comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice or skilled nursing facility (SNF) services are ending. This appeal right already existed for Medicare beneficiaries enrolled in Medicare managed care programs.
There are two notices required by these regulations. The first is a generic notice 
(called a Notice of Medicare Provider Non-Coverage) that the provider will deliver whenever a beneficiary's Medicare coverage of current items and/or services is ending. Note that beneficiaries receiving skilled nursing services in swing bed settings—both PPS and critical access hospitals—should get this generic notice instead of a hospital issued notice of noncoverage (HINN). The phone number for the QIO that should be included in this notice is 1-800-432-0407. The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate Quality Improvement Organization (QIO) only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end.
Expedited appeals will be conducted by the KFMC Review Team as part of KFMC's responsibilities as the Medicare QIO for Kansas. Appeals will require that a copy of the beneficiary's medical record be provided to KFMC no later than close of business of the day the request for an appeal was made.
Example generic and detailed notices and more information regarding these procedures are included below. For additional information about this expedited review process, please visit here.
Files (Documents are in Microsoft Word format unless noted otherwise)
- Notice of Medicare Provider Non-Coverage (Generic Notice)
- Detailed Explanation of Provider Non-Coverage (Detailed Notice)
- Revised Expedited Determination Qs and As March 06
- Notice of Medicare Provider Non-Coverage (Generic Notice, Spanish)
- Detailed Explanation of Provider Non-Coverage (Detailed Notice, Spanish)
- QIO Procedure for Expedited Termination of Service Appeal Review
- Appeal review one-page overview
- Quick Tips Wallet Card
- Benefits Improvement and Protection Act Presentation
- BIPA Fact Sheet
- Medicare Patients Information for Comprehensive Outpatient Rehabilitation Facilities (CORFs)
- Medicare Patients Information for Home Health Agencies (HHAs)
- Medicare Patients Information for Hospices
- Medicare Patients Information for Skilled Nursing Facilities (SNFs)