You have the right to a fast appeal if you think your services from a Medicare-covered skilled nursing facility (SNF), home health agency (HHA), comprehensive outpatient rehabilitation facility (CORF), or hospice are ending too soon.
While you're getting SNF, HHA, CORF, or hospice services, you should get a notice called "Notice of Medicare Provider Non-Coverage" at least 2 days before covered services end. If you don't get this notice, ask for it. This notice explains:
- The date your covered services will end
- That you may have to pay for services you get after the coverage end date given on your notice
- Information on your right to get a detailed notice about why your covered services are ending
- Your right to a fast appeal and information on how to contact the QIO in your state to request a fast appeal
How do you ask for a fast appeal?
Ask the QIO for a fast appeal no later than noon of the day before your Medicare-covered services end. Follow the instructions on the "Notice of Medicare Provider Non-Coverage."
If you miss the deadline for requesting an expedited (fast) appeal, you can still ask the QIO to review your case, but different rules and timeframes apply.
What will happen during the QIO's review?
When the QIO gets your request, it will notify the provider. Then, by the end of the day that the provider gets the notice from the QIO, the provider will give you a "Detailed Explanation of Non-Coverage." The notice will include:
- Why your services will no longer be covered
- The applicable Medicare coverage rule or policy, including a citation to the applicable Medicare policy, or information on how you can get a copy of the policy that's being used to explain why your coverage is ending
- How the applicable Medicare coverage rule or policy applies to your situation
If the QIO decides that your services are ending too soon:
Medicare may continue to cover your SNF, HHA, CORF, or hospice services (except for applicable coinsurance or deductibles).
If the QIO decides that your services should end:
You won't be responsible for paying for any SNF, HHA, CORF, or hospice services provided before the termination date on the "Notice of Medicare Provider Non-Coverage." If you continue to get services after the coverage end date, you may have to pay for those services.
How Medicare recovers conditional payments
If Medicare makes a conditional payment, you or your representative should call the Medicare Coordination of Benefits Contractor (COBC).
The COBC will notify the recovery contractor to work on your case. The recovery contractor is a separate contractor who uses the information you or your representative gives to the COBC to see Medicare gets repaid for the conditional payments.
The recovery contractor will gather information about any conditional payments Medicare made related to your pending settlement, judgment, or award. Once a settlement, judgment, or award is final, you or your representative should call the recovery contractor. The recovery contractor will get the final repayment amount (if any) on your case and issue a letter requesting repayment.