Fee For Service Medicare Appeals
NON-HOSPITAL APPEALS
Fee-For-Service (i.e., original Medicare) Medicare beneficiaries have the right to appeal decisions related to their Medicare provider’s decision to end Medicare-covered skilled services in the nursing home or hospice setting or provided by a home health agency.
The official notice to end covered services is called a “Notice of Medicare Provider Non-Coverage.” The Notice of Medicare Provider Non-Coverage must be delivered no later than the day before coverage will end.
When you receive a Notice of Medicare Provider Non-Coverage, if you disagree with the decision that skilled 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 must call Masspro no later than noon the day before the “Effective Date” listed on the notice.
- Call Masspro’s helpline at 1-800-252-5533, or the national Medicare Helpline at 1-800-MEDICARE (800-633-4227).
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 after-hours helpline message and follow the instructions to leave a message.
Note: Beneficiaries appealing the end of home health services must also have a certification from a physician.
- A Masspro customer service representative will contact you to discuss the case with you and ask you for your views.
- The review case manager and a physician will look over your medical record. Masspro can take approximately 72 hours from the time of your call to complete the review.
- We will inform you, your doctor 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 Provider Non-Coverage to Masspro at any time during your stay or within 30 days after the end of services.
HOSPITAL APPEALS
When you are admitted to a hospital as an inpatient, the hospital is required to give you an Important Message from Medicare. This Important Message explains that you have the right to appeal a discharge decision and how to request an appeal.
Discharge Decision
If you disagree with the decision that you are ready to be discharged, 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 of your planned discharge date.
- Call Masspro’s helpline at 1-800-252-5533, or the national Medicare Helpline at 1-800-MEDICARE (800-633-4227).
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 after-hours helpline message and follow the instructions to leave a message.
- The review case manager and a physician will look over your medical record.
- We will inform you and the hospital of our decision, first by phone and then in a letter. We will also tell you about your other appeal rights.
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.
|
