Introduction to Medicare Coverage, and the Appeals Process
Generally, Medicare coverage is available when services are medically reasonable and necessary for treatment or diagnosis of illness or injury, or to maintain or prevent deterioration of a condition.
Part A Coverage
- Inpatient hospital services (note: the appeals process for Inpatient Hospital Services currently differs from the standard process outlined below).
- Inpatient skilled nursing facility services
- Some home health Services
- Hospice services
Part B Coverage
- Physicians’ services;
- Some home health Care;
- Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians’ services;
- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;
- X-ray therapy, radium therapy and radioactive isotope therapy;
- Surgical dressings, and splints, casts and other devices used for fractures and dislocations;
- Durable medical equipment;
- Prosthetic devices;
- Braces, trusses, artificial limbs and eyes;
- Ambulance services;
- Some outpatient and ambulatory surgical services;
- Some outpatient hospital services;
- Some physical therapy services;
- Some occupational therapy;
- Some outpatient speech therapy;
- Comprehensive outpatient rehabilitation facility services;
- Rural health clinic services;
- Institutional and home dialysis services, supplies and equipment;
- Ambulatory surgical center services;
- Antigens and blood clotting factors;
- Qualified pyschologist services;
- Therapeutic shoes for patients with severe diabetic foot disease;
- Influenza, Pneumococcal, and Hepatitis B vaccine;
- Some mammography screening;
- Some pap smear screening, breast exams, and pelvic exams;
- Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.
Tip – For a more detailed look at Part B coverage, see our Medicare Part B page.
Tip – for a list of non-covered items and services, see this release from the Centers for Medicare & Medicaid Services (CMS)
Standard Appeals for Parts A & B
- No minimum claim amount
- Must be filed within 120 days of receipt of “Initial Determination”
- Filed with Medicare Contractor
- Reviewed and decided by Medicare Contractor
2. Reconsideration Determination
- No minimum claim amount
- Must be filed within 180 days of receipt of “Redetermination”
- Filed with Qualified Independent Contractor (QIC)
- Reviewed by Qualified Independent Contractor (QIC)
- Decisions must be issued within 60 days, or case can be escalated to ALJ, below
3. Administrative Law Judge (ALJ) Hearing
- Amount in controversy must be at least $160.00 for 2017
- Must be filed within 60 days of receipt of “Reconsideration Determination”
- Filed with Office of Medicare Hearings and Appeals (OMHA)
- Reviewed and decided by an Administrative Law Judge from the U.S. Dept of Health and Human Services
4. Medicare Appeals Council (MAC)
- Amount in controversy must be at least $160.00 for 2017
- Must be filed within 60 days of receipt of ALJ “Hearing Decision”
- Filed with U.S. Dept of Health and Human Services
- Reviewed and decided by U.S. Dept of Health and Human Services Medicare Appeals Council
5. Judicial Review
- Amount in controversy must be at least $1560.00 for 2017
- Must be filed within 60 days of receipt of “MAC Decision”
- Filed with U.S. District Court
- Reviewed and decided by U.S. District Court
Beneficiaries may seek “expedited review” of a skilled nursing facility, home health, hospice or comprehensive outpatient rehabilitation facility (CORF) services discharge or termination.
Expedited review is available in cases involving a discharge from the provider of services, or a termination of services. A reduction in service is not considered a termination or discharge for purposes of triggering expedited review except in the case of skilled nursing facility care when the reduction of care from daily to intermittent will mean that the beneficiary is no longer eligible for Part A coverage. For home health care and CORF services, a successful appeal requires that a physician certify that “failure to continue the provision of such services is likely to place the individual’s health at risk.”
The provider must give the beneficiary a general, standardized notice at least two days in advance of the proposed end of the service. If the service is fewer than two days, or if the time between services is more than two days, then notice must be given by the next to last service. The notice describes the service, the date coverage ends, the beneficiary’s financial liability for continued services, and how to file an appeal.
A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination with the QIO in the state in which the beneficiary is receiving the services at issue. The request may be made in writing or by telephone, but the request must be made no later than noon of the calendar day following receipt of the provider’s notice of termination. If the QIO is unavailable to accept the beneficiary’s request, the beneficiary must submit the request by noon of the next day the QIO is available. At that time, the beneficiary is given a more specific notice that includes a detailed explanation of why services are being terminated, a description of any applicable Medicare coverage rules and information on how to obtain them, and other facts specific to the beneficiary’s case. The beneficiary is not financially liable for continued services until two days after receiving the notice, or the termination date specified on the notice, whichever is later.
Coverage of the services at issue continues until the date and time designated on the termination notice, unless the QIO reverses the provider’s service termination decision. If the QIO’s decision is delayed because the provider did not timely supply necessary information or records, the provider may be liable for the costs of any additional coverage, as determined by the QIO. If the QIO finds that the beneficiary did not receive valid notice, coverage of the provider services continues until at least 2 days after valid notice has been received. Continuation of coverage is not required if the QIO determines that coverage could pose a threat to the beneficiary’s health or safety.
If the QIO upholds the decision to terminate services or discharge the beneficiary, the beneficiary may request expedited reconsideration, orally or in writing, by noon of the calendar day following the QIO’s initial notification. The reconsideration will be conducted by the QIC, which must issue a decision within 72 hours of the request. If the QIC does not comply with the time frame, the beneficiary may “escalate” the case to the administrative law judge level.
Beneficiaries retain the right to utilize the standard appeals process rather than the new expedited process in all situations. A QIO may review an appeal from a beneficiary whose request is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.
Special Rules for Hospital Claims
Hospital inpatients denied Medicare during their stay may request an “expedited review” of a Medicare denial by the QIO. These expedited requests must be decided by the QIO within three working days.
Under previous regulations, a hospital inpatient who received a denial notice from the hospital and requested review immediately avoided being charged until the QIO issued an initial determination. However, the new expedited appeals regulations protect only those inpatients who did not know or could not reasonably have been expected to know that payment would not be made from liability.
A beneficiary may request reconsideration review by the QIC for an unfavorable decision. If the reconsideration decision is unsatisfactory and at least $200 remains in controversy, the beneficiary may request an ALJ hearing. Hearing requests must be made within 60 days of receipt of the notice of the reconsideration decision. The hearing request should be made in writing and should be filed with the entity identified in the reconsideration notice.
If the hearing request is unsatisfactory, a beneficiary may request a review from the Medicare Appeals Council (MAC). The request must be made within 60 days of receipt of the hearing decision. If $2,000 remains in controversy after the hearing, the case may proceed into United States District Court.
Medicare Advantage Appeals
A Medicare Advantage (MA) enrollee also has the right to appeal if the MA plan denies coverage for a service. An MA plan is required to provide enrollees with information regarding the appeals process as part of the plan materials. The appeals procedures for Medicare Part C, including the timeframes for requesting appeals, are different than the appeal procedures for traditional Medicare. In MA cases, initial determinations are known as “organization determinations. ” Organization determinations as well as the next level of review, reconsideration determinations , are made by the MA plan. If a reconsidered decision is denied in whole or in part, it is sent automatically to the Part C Independent Review Entity (IRE), an external review organization hired by CMS to review Medicare Advantage reconsidered decisions. The IRE decision may be appealed to an ALJ, as in Part A or Part B appeals above.
In addition, MA plans are required to have internal grievance procedures. The MA plan must provide information to members regarding this grievance process in the plan’s written membership rules, along with timetables and information about the steps necessary to utilize the grievance process. Grievance procedures are separate and distinct from the appeals procedures. The grievance procedures are to be used in all cases that do not involve an “organization determination.” For example, controversies about hours of service, location of facilities, or courtesy of personnel would go through the grievance process. A grievance must be filed either orally or in writing no later than 60 days after the circumstance giving rise to the grievance.
Articles & Updates
- Self-Help Materials Mar 14, 2017
- Coverage & Appeals Feb 27, 2017
- Medicare Basics Feb 27, 2017
- CMS Issues New Rules Governing Medicare Appeals Feb 8, 2017
- Center Comments on Proposed Rule that Would Significantly Alter the Medicare Administrative Appeals Process Aug 29, 2016
- “Discharge” from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? Jan 13, 2016
- The Medicare Dental Exclusion: Is it Being Used to Deny Vulnerable Beneficiaries Needed Care? May 28, 2015
- Saga of an Inpatient Hospital Appeal: Notice and Use of Lifetime Reserve Days and Comments on Observation Status May 21, 2015
- Making Sense of Medicare’s Preventive Service Benefits Sep 20, 2012
- Court Emphatically Rejects Beneficiaries’ Right to Sue a Part D Plan When the Plan Delays Enrollment Sep 30, 2010