You may have the right to a fast appeal if you think your services are ending too soon from one of these facilities:
- A Medicare-covered skilled nursing facility (SNF)
- A Medicare-covered (HHA)
- A Medicare-covered (CORF)
- A Medicare-covered facility
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 before the termination date listed on your "Notice of Medicare Non-Coverage." Follow the instructions on the 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.
Additional Resources Related to Discharge Appeal:
The Beneficiary Care Management Program (BCMP) is a CMS Person and Family Engagement initiative supporting Medicare Fee-for-Service beneficiaries undergoing a discharge appeal, who are experiencing chronic medical conditions requiring lifelong care management. It serves as an enhancement to the existing beneficiary appeals process. This program is not only a resource for Medicare beneficiaries, but extends support for their family members, caregivers and providers as active participants in the provision of health care delivery.
The BCMP program will focus on these key care management support services:
- Discharge Planning and Care Coordination
- Healthcare Care Navigation, and
- Beneficiary Empowerment and Self Care
The BCMP program is a referral-based program, initiated by your respective Regional BFCC-QIO. If you or a family member have an active discharge appeal, we encourage you to contact the Regional BFCC-QIO to discuss if you could benefit from this service. At your convenience, you may also access additional program information at: https://www.bcmpqio.org.