Review for Beneficiary Appeals of Provider Notices

Patients deserve to have the best health care possible, and they have guaranteed rights and protections as individuals with traditional Medicare or Medicare Advantage coverage. That's 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. The notice is provided at least two days before care ends.

Types of notices include:

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

 Once a patient receives a written notice, they can request an expedited (fast-track) review if the patient or their designated representative thinks they still need care and that Medicare should continue to pay for it. If a patient receives a notice and they would like CCME to review the case, we can be contacted at 866-885-4902 in North Carolina and 800-922-3089 in South Carolina

 To comply with federal guidelines, CCME must process beneficiary appeals within a very short timeframe. Key factors to the successful implementation of expedited determinations include:

• CCME being available weekdays, weekends, and holidays.
• Providers are responsible for providing medical records upon request from CCME (weekdays, weekends, and holidays) in a timely manner.
• The Advance Notice is to be delivered to the beneficiary no later than two days before the proposed end of services.
• The deadline for requesting a review by CCME is noon of the day prior to the effective date on the notice.
• The day the appeal is requested, CCME will request the medical records.
• The attending physician is required to give his/her input as part of the appeal process.
• Review determinations will be provided verbally followed by written notice. Telephone notice of determination must be made within 72 hours of the appeal receipt.

When CCME requests patient's records, we typically need the patient's medical record and completed Advance Notice, Detailed Notice, or Important Message faxed to us.Once CCME receives the patient's records, we will assign an independent physician to review the case and make a decision. Our review team will notify the beneficiary (or representative), provider, patient's physician, and financial intermediary of the outcome right away.

For more information or to download copies of the notices, please visit the Beneficiary Notices Initiative section of the Centers for Medicare & Medicaid Services (CMS) website. For questions regarding appeals and beneficiary complaints, contact Rita Scott at rscott@scqio.sdps.org.