Instructions issued for M+C patients' new review rights

Healthcare Financial Management, March, 2004

Effective January 1, 2004, enrollees of Medicare Choice (M C) plans have the right to an expedited review by a quality improvement organization when enrollees disagree with their M C plan's decision to terminate Medicare coverage of services from a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility, according to a January 9, 2004, CMS transmittal. This implementing final rule was published in the April 4, 2003, Federal Register.

CMS also noted that Section 1869(b)(1)(F) of the Social Security Act establishes a parallel right to an expedited review for "fee-for-service" Medicare beneficiaries. CMS expects to implement similar procedures for these beneficiaries later in 2004.

CMS also has added more comprehensive guidance to its web site for patients and providers, in response to many questions it had received about the new appeal procedures. Under the expedited-review requirement, providers must deliver the Notice of Medicare Noncoverage at least two days before planned termination of Medicare coverage of the services.

To read Transmittal 41 on new enrollee rights in the M C program, go to www.cms.gov/manuals/ pm_trans/R410TN.pdf.

To read the additional managed care appeals guidance, go to www.cms.hhs.gov/healthplans/appeals.>

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