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Medicare Advantage Appeals
Important Update, March 2012 CMS has issued a new combined Notice of Medicare Non-Coverage, which will replace CMS 10123 and CMS 10095 forms. This combined notice retains the CMS 10123 form number, and it’s name - Notice of Medicare Non-Coverage, or NOMNC.
Providers are required to issue the new combined notices as soon as possible, but no later than May 1, 2012.
Click here to read more about this update for MA notices.
Beneficiaries enrolled in a Medicare Advantage plan (or other Medicare health plans that are not fee-for-service) have the right
to appeal decisions related to their Medicare Advantage plan’s decision to end Medicare-covered skilled services in the nursing home setting or provided by a home health agency.
The official notice to end covered services is called a “Notice of Medicare Non-Coverage.” The plan must deliver the Notice of Medicare Non-Coverage no later than two days before coverage will end.
When you receive a Notice of Medicare Non-Coverage, if you disagree with the decision that services should end, you have the right to request an appeal from Masspro. You can ask a family member or friend to represent you during the appeal. You or your designated representative must call Masspro no later than noon the day before the “Effective Date” listed on the notice.
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Call Masspro’s helpline at 1-800-252-5533 (TTY users, please call 1-781-419-2502).
Note: If you call Masspro’s helpline outside of normal business hours (Monday−Friday, 8:30 am−5:00 pm), make sure to listen carefully to the helpline message and follow the instructions to leave a message.
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The review case manager and a physician will look over your medical record. Masspro can take up to one calendar day from the time of your call to complete the review.
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We will inform you, the Medicare Advantage plan and your provider of our decision, first by phone and then in a letter. We will also tell you about your other appeal rights.
If you miss the deadline to request an appeal from Masspro, you may still appeal the Notice of Medicare Non-Coverage through your Medicare Advantage plan.
Notice of Discharge and Medicare Appeal Rights (IM)
Beneficiaries enrolled in a Medicare Advantage plan (or other Medicare health plans that are not fee-for-service) have the right
to appeal decisions related to their Medicare Advantage plan’s decision to end Medicare-covered services in the in-patient hospital setting.
The official notice to end covered services is called an Important Message from Medicare About Your Rights. The plan must deliver the IM no later than the day before coverage will end.
When you receive an IM, if you disagree with the decision that hospital care should end, you have the right to request an appeal from Masspro. You can ask a family member or friend to represent you during the appeal. You must call Masspro no later than midnight the day of the planned discharge.
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Call Masspro’s helpline at 1-800-252-5533 (TTY users, please call 1-781-419-2502).
Note: If you call Masspro’s helpline outside of normal business hours (Monday−Friday, 8:30 am−5:00 pm), make sure to listen carefully to the helpline message and follow the instructions to leave a message.
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The review case manager and a physician will look over your medical record. Masspro can take up to one working day from the time of your call to complete the review.
- We will inform you, the Medicare Advantage plan and the hospital of our decision, first by phone and then in a letter.
If you miss the deadline to request an appeal from Masspro, you may still appeal the IM through your Medicare Advantage plan.
The Center for Medicare Advocacy can give you advice and free legal help during the appeals process. For more information, call them at 1-800-323-3205.
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