Beneficiary Appeals of Provider Notices

You deserve to get the best health care possible. CCME and Medicare want to make sure you get that care. That is why Medicare-certified health care providers are required to provide Medicare patients with routine written "Notice of Non-Coverage" in all inpatient and some outpatient settings. If your health care provider believes that it is not medically necessary for you to continue your current course of treatment, you will be given one of the following:

• Notice of Medicare Provider Non-Coverage
• Hospital-Issued Notice of Non-Coverage
• An Important Message From Medicare

Many times these notices are appropriate because your condition has improved and you no longer need that service. Once you receive a written notice that your inpatient hospital care or other medical service is about to end, you can request an appeal if you believe that you still need these services. You have the right to request an appeal for:

• An Impending Hospital Discharge – Sending you home when you believe you are too sick to leave and should continue to stay in the hospital longer.
• Termination of Service – Ending a course of treatment (such as rehabilitation, nursing home, home health, or hospice care) when you feel you still need those services.

It is important to begin the appeal process quickly. You must call CCME as soon as the notice is issued. CCME can review your medical record to determine if the services should continue if you feel that Medicare-covered services are ending too soon (based only on your medical status).

How Do I Appeal?

• Call CCME’s Beneficiary Appeals Helpline in North Carolina at 866-885-4902 and in South Carolina at 800-922-3089. You or your designated representative may request the appeal. If you call outside of our normal business hours (8:00 a.m. – 4:30 p.m. ET, 7 days a week), leave a message on our answering machine. We will call you back the next business day. You can leave a message at any time, on any day.
• Have the following information handy and ready to discuss:
  • Name on Medicare card
  • Medicare number
  • Type of Medicare plan (Traditional Medicare or Medicare Advantage)
  • Address
  • Phone number (including area code)
  • Date of birth
  • Name, address, and phone number of the health care provider
  • Date the service was provided
  • Copy of any notice/letter the provider issued
• If you have to leave a message, be sure to provide CCME with:
  • Patient’s name
  • Medicare and Social Security numbers
  • Name of the health care facility
  • Date the notice was issued
  • Phone number (including area code) where you can be reached
• Tell the health care provider that you called CCME.

Review Process

1. CCME will discuss your situation with you or your designated representative.
2. Then CCME will contact the facility to request your medical record.
3. An independent physician will then review the documentation and determine whether your current course of treatment is medically necessary.
4. CCME will notify you and your health care provider of our decision right away.

For more information on how CCME can help you with your appeal, contact us at 866-885-4902 in North Carolina and 800-922-3089 in South Carolina. You may also call Medicare at 1-800-MEDICARE (1-800-633-4227), TTY/TTD 1-877-486-2048, or visit Medicare’s website.