Medicare Advantage Discharge Appeals-Grijalva-MA Appeals for SNF, HHA, and CORF
Medicare Advantage enrollees have the right to an expedited review by Kansas Foundation for Medical Care when they disagree with their plan's decision that coverage of their services from a skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF) should end.
Medicare Advantage must provide an advance notice of Medicare coverage termination to Medicare Advantage enrollees no later than two days before coverage ends. If the patient does not agree that covered services should end, they may request a Fast Track review by Kansas Foundation for Medical Care. The review process will generally be completed within 48 hours of the enrollee's request.
The SNF, HHA and CORF notification and appeal requirements may distribute responsibilities between four parties:
The Medicare Advantage plan determines the termination date and provides (upon request) a detailed explanation of termination. The plan must also provide Kansas Foundation for Medical Care with required information (medical records) to complete an appeal review. Medicare Advantage plans may choose to delegate these responsibilities to their contracting providers.
The provider delivers the Notice of Medicare Non-Coverage (NOMNC), upon direction from the plan, to enrollees no later than two days or two visits before their covered services end.
The Medicare Advantage enrollee or authorized representative acknowledges receipt of the notice and contacts Kansas Foundation for Medical Care (within the specified timeframe) for an expedited review.
Kansas Foundation for Medical Care will immediately contact the Medicare Advantage organization and the provider when an expedited review is requested. They will also process the appeal and make a decision within one day after receiving all the necessary information. Kansas Foundation for Medical Care must be available to receive and process appeals during normal business hours, seven days per week, including weekends and holidays.
Kansas Foundation for Medical Care encourages providers to work with Medicare Advantage plans to establish processes for issuing these notices in an appropriate and timely manner. A provider does not have to agree with the decision that covered services should end, but must still carry out this function under its Medicare provider agreement. For more information contact us at 800-432-0407.
Downloads
To download up-to-date Notices of Non-Coverage and Detailed Explanation click on the following: