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Beneficiary and Family Centered Care
Appeals
Under the Beneficiary Protection Program, Medicare beneficiaries have the right to appeal decisions to end their Medicare-covered services in both hospital and non-hospital (nursing home, home health, hospice) settings. Masspro is responsible for reviewing the beneficiary’s medical record to provide an objective determination of whether services have ended prematurely.
Please refer to the CMS Beneficiary Notice Initiative website for information regarding notices of non-coverage.
Fee For Service Expedited Notice also known as Notice of Medicare Provider Non Coverage and instructions can be found here.
Medicare Advantage (Medicare Health Plans) Expedited Notice also known as Notice of Medicare Non Coverage and instructions can be found here.
Hospital Discharge Appeal Notices and instructions can be found here.
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 FFS notices.
Click here to read more about this update for MA notices.
Quality of Care Concerns
Medicare beneficiaries have rights and protections, especially the right to quality health care. Beneficiaries who have a concern or are not satisfied with their care can file a quality of care concern with Masspro. Examples of quality of care issues include service delay, omission of treatment, the provision of unnecessary care, and medication issues.
After a quality of care concern is filed, a physician/nurse review team examines the care provided and makes an initial finding regarding whether standard guidelines or expected practices were followed. The provider is then informed about the results of the complaint review, and given the chance to comment. If indicated, Masspro staff members work with providers to improve care.
Masspro offers a helpline, 1-800-252-5533 (TTY users, please call 1-877-486-2048), available 24 hours a day, including holidays and weekends, where beneficiaries can begin the appeals process, report a quality of care concern, or receive assistance in finding other helpful resources.
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