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Medicare Quality Improvement Organization (QIO) Review Responsibilities under the Benefits Integrity and Protection Act (BIPA) of 2000
Primaris has been designated, as detailed below, by the Centers for Medicare & Medicaid Services (CMS) as the independent review entity (IRE) to conduct appeal reviews for Medicare fee-for-service beneficiaries who have been notified of their impending termination of services or discharge from a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, or skilled nursing facility (SNF) (including swingbed providers) .
A beneficiary has a right to an expedited determination by Primaris when the beneficiary disagrees with the provider that services should be terminated (and in the home health and comprehensive outpatient rehabilitation settings a physician certifies that failure to continue the provision of the service(s) may place the beneficiary’s health at significant risk). A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination to Primaris by no later than noon of the calendar day prior to termination of the Medicare-covered services. The beneficiary may submit evidence to be considered by Primaris in making their decision. Coverage of provider services continues until the date and time designated on the termination notice, unless Primaris reverses the provider’s service termination decision.
BIPA Discharge Appeals: 42 CFR 405.1204(d)(2) requires that the QIO provide a beneficiary, at his request, with either a copy of, or access to, any documentation that the QIO sent to the Qualified Independent Contractor. This also applies to the documentation related to initial denial determinations, Primaris will not redact names of physicians or providers from documentation to be given to the beneficiary. Beneficiary requests will be accommodated no later than by close of business of the first day after the request was received.
Citation and Procedure
According to the Federal Register published on Friday, November 26, 2004, (42CFR Parts 405 & 489 Medicare Program; Expedited Determination Procedures for Provider Service Terminations; Final Rule), before the termination of Medicare-covered services, the provider (CORF, HHA, hospice, or SNF) must deliver valid written notice to the beneficiary of the provider’s decision to terminate services. The provider must use a standardized notice as specified by CMS. The provider must also notify the beneficiary of the decision to terminate covered services no later than two days before the proposed end of the services. If, in a non-residential setting, the span of time between services exceeds two days, the notice must be given no later than the next to last time services are furnished.
Within 72 hours from receipt of an expedited appeal request, Primaris must make a determination on whether termination of Medicare coverage is the correct decision. If a beneficiary makes an untimely request for an expedited determination, Primaris will accept the request and make a determination as soon as possible, but the 72-hour time frame and the financial liability protection do not apply.
Primaris will be available seven days a week during business hours to receive requests for appeals. When Primaris receives a request for an expedited determination, the provider of services will be notified by telephone and by facsimile. The provider of services will be required to provide the necessary documentation requested by Primaris no later than close of business of the day Primaris notified the provider of the appeal. For requests made close to the close of business, the timeframe may be extended to the next morning. Primaris will also notify the provider of services of the need to provide a detailed notice of termination to the enrollee by close of business of that day.
Required Content of Termination Notice
The standardized termination notice must include:
- The date the coverage of services ends;
- The date that the beneficiary’s financial liability for continued services begins;
- A description of the beneficiary’s right to an expedited determination including information about how to request an expedited determination and about a beneficiary’s right to submit evidence showing that services must continue;
- Notice of the beneficiary’s right to receive the detailed information why services are no longer reasonable and necessary or are no longer covered; and
- Primaris’ name and beneficiary helpline toll-free number (800) 347-1016
You will find sample copies of the generic notice, entitled “Notice of Medicare Provider Non-coverage,” and the detailed notice, along with instructions on how to complete both notices on CMS’s website.
If you have questions regarding this information, please contact Rita Ketterlin at 1-800-735-6776, ext. 153.