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Original Medicare (Fee-for-service) Appeals

Important News for Beneficiaries: Jimmo Re-Review Information

Background
On January 24, 2013, the U.S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius (Jimmo).  As part of the Jimmo settlement agreement, Medicare clarified that maintenance coverage under the skilled nursing facility (SNF) and home health (HH) benefits, and skilled therapy under the SNF, HH, and outpatient therapy (OPT) benefits does not depend on whether the patient can improve, but on whether skilled care is required and whether the services themselves are reasonable and necessary.  The Jimmo vs. Sebelius case fact sheet is available online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf).   

Re-review of Denied Claims
The Jimmo settlement agreement also provides for the re-review of certain Medicare claims under clarified maintenance coverage standards for the SNF, HH, and OPT benefits, applicable when a patient has no restoration or improvement potential, but that patient requires skilled SNF, HH, or OPT services to maintain, or to prevent or slow further deterioration of, his or her clinical condition.  

Beneficiaries, please click on the link below to access the proper form for requesting a re-review of your claim pertaining to the Jimmo settlement:

Request for Re-Review of Medicare Claims Related to the Settlement Agreement in Jimmo V. Sebelius
 

Standard Appeals Process

Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions.

There are five levels in the Medicare Part A and Part B appeals process. The levels are:

  1. First Level of Appeal:    Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).
  2. Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
  3. Third Level of Appeal:   Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
  4. Fourth Level of Appeal: Review by the Medicare Appeals Council
  5. Fifth Level of Appeal:    Judicial Review in Federal District Court

Appointment of Representative

A party may appoint any individual, including an attorney, to act as his or her representative to help the party during the processing of a claim or claims and /or any appeals of claims.  A representative may be appointed at any time during the appeals process.  The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696; a link to this form can be found in the "Related Links" section below) or use a conforming written instrument.  If the form CMS-1696 is not used, the written request must contain all of the elements listed in 42 CFR 405.910 (a link to this section of the regulation can be found in "Related Links" below).  The appointment of representative is valid for one year from the date it is signed by both the party and  the appointed representative.  A detailed explanation of appointment of a representative can also be found in the CMS Internet Only Manual (IOM) 100-4, Chapter 29, section 270 (see below in "Related Links").

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices with beneficiaries enrolled in the original Medicare (fee-for-service) plan are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.

For more detailed information about the Expedited Determination Appeals Process, go to the "Related Links" section below.  

For more detailed information about each level of appeal, go to the left side of this page. A downloadable brochure from the Medicare Learning Network (MLN) designed as a quick reference to the claims appeals process for providers, physicians and other suppliers can be found in the "Related Links" section below.  To see a diagram of the original Medicare (fee-for-service) standard and expedited appeals process, go to the "Downloads" section below.