When you are a patient in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), you have the right to get all the SNF, HHA or CORF care covered by the Plan that is necessary to diagnose and treat your illness or injury. The day we end coverage for your SNF, HHA or CORF services is based on when these services are no longer medically necessary. This part explains what to do if you believe that coverage for your services is ending too soon.
Complaints (Appeals) - Skilled Nursing Facility
Do you think you need more coverage time in a nursing or high-level care facility? Follow the instructions to appeal the decision.
Your provider will give you written notice called Notice of Medicare Non-Coverage at least 2 days before coverage for your services ends. Call Customer Services or 1-800 MEDICARE (1-800-633-4227) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI/. You (or your representative) will be asked to sign and date this notice to show that you received it. Signing the notice does not mean that you agree that coverage for your services should end – only that you received and understood the notice.
You have the right to appeal our decision to end coverage for your services. As explained in the notice you get from your provider, you may ask KEPRO to do an independent review of whether it is medically appropriate to end coverage for your services.
You must quickly contact KEPRO. The written notice you got from your provider gives the name and telephone number of your KEPRO and tells you what you must do.
- If you get the notice 2 days before your coverage ends, you must contact KEPRO no later than noon of the day after you get the notice.
- If you get the notice more than 2 days before your coverage ends, you must make your request no later than noon of the day before the date that your Medicare coverage ends.
KEPRO will ask why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. KEPRO will also look at your medical information, talk to your doctor, and review information that we have given to KEPRO. During this process, you will get a notice called the Detailed Explanation of Non-Coverage giving the reasons why we believe coverage for your services should end. Call Customer Services or 1-800-MEDICARE (1-800-633-4227 – TTY users should call 1-877-486-2048) to get a sample notice or see it online at http://www.cms.hhs.gov/BNI/.
KEPRO will make a decision within one full day after it receives all the information it needs.
We will continue to cover your SNF, HHA or CORF services (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.
You will not be responsible for paying for any SNF, HHA, or CORF services provided before the termination date on the notice you get from your provider. You may stop getting services on or before the date given on the notice and avoid any possible financial liability If you continue receiving services, you may still ask KEPRO to review its first decision if you make the request within 60 days of receiving KEPRO’s first denial of your request.
KEPRO has 14 days to decide whether to uphold its original decision or agree that you should continue to receive services. If KEPROagrees that your services should continue, we must pay for or reimburse you for any care you have received since the termination date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.
If KEPRO upholds its original decision, you may be able to appeal its decision to an Administrative Law Judge (ALJ). Please see Appeal Level 3 Part 1 for guidance on the ALJ appeal. If the ALJ upholds our decision, you may also be able to ask for a review by the Medicare Appeals Council (MAC) or a Federal Court. If either the MAC or Federal Court agrees that your stay should continue, we must pay for or reimburse you for any care you have received since the termination date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.
If you do not ask KEPRO for a review by the deadline, you may ask us for a fast appeal.
If you ask us for a fast appeal of your coverage ending and you continue getting services from the SNF, HHA, or CORF, you may have to pay for the care you get after your termination date. Whether you have to pay or not depends on the decision we make.
If we decide, based on the fast appeal, that coverage for your services should continue, we will continue to cover your SNF, HHA, or CORF services (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described your Evidence of Coverage.
If we decide that you should not have continued getting services, we will not cover any services you received after the termination date.
If we uphold our original decision, we will forward our decision and case file to the Independent Review Entity (IRE) within 24 hours. Please see the Appeal Level 2 section above for guidance on the IRE appeal. If the IRE upholds our decision, you may also be able to ask for a review by an ALJ, MAC, or a Federal court. If any of these decision makers agree that your stay should continue, we must pay for or reimburse you for any care you have received since the discharge date on the notice you got from your provider, and provide you with any services you asked for (except for any applicable co-payments or deductibles) for as long as it is medically necessary and you have not exceeded our Plan coverage limitations as described in your Evidence of Coverage.
For questions or doubts about this process, call Members Services.
