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How do I get a fast appeal in a setting other than a hospital?

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 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 Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your state to request a fast appeal

How do I ask for a fast appeal?

Ask the BFCC-QIO for a fast appeal no later than noon of the first day after the day you get the "Notice of Medicare  Non-Coverage." Follow the instructions on the termination notice.

If you miss the deadline for requesting a fast appeal from the BFCC-QIO, you can request a fast reconsideration from your plan, but services will only be covered if there's a decision issued in your favor.

What will happen during the BFCC-QIO's review?

When the BFCC-QIO gets your request, it will notify the provider. Then, by the end of the day that the provider gets the notice from the BFCC-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

The BFCC-QIO will:

  • Ask why you believe coverage for the services should continue
  • Look at your medical records and the information provided by the plan
  • Make a decision by close of business the day after it gets the information it needs to make a decision

If the BFCC-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 BFCC-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 Non-Coverage." If you continue to get services after the coverage end date, you may have to pay for those services.