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How to File an Appeal We are the Medicare Quality Improvement Organization, working to improve the quality of care for Medicare beneficiaries. Our site offers beneficiary and family-centered care information for providers, patients, and families. Welcome! |
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hospital appeals
If you have Medicare, you have the right to appeal a hospital discharge if you feel too sick to leave, even if you have a Medicare Advantage plan. The hospital will provide you with a document called "An Important Message from Medicare." This document tells you how to appeal the discharge.
If you call Kepro for an appeal, Kepro’s physician will look at the medical record to see if you should stay in the hospital. Then you will be informed of the decision.
During the appeal,
- You do not have to leave the hospital.
- You do not have to pay for the extra days in the hospital while Kepro reviews the medical record.
skilled services appeals
If you have Medicare, you have the right to appeal a discharge if you do not agree with the decision that skilled services will be stopped. You must be given a letter called a Notice of Medicare Non-coverage with the planned discharge date explaining how to appeal, even if you have a Medicare Advantage plan.
Once you receive the letter, you can call Kepro. Kepro’s physician will look at the medical record to see if the services should continue, and then you will be informed of the decision.
beneficiary care management program (bcmp)
The Beneficiary Care Management Program (BCMP) is a Centers for Medicare & Medicaid Services (CMS) Person and Family Engagement initiative supporting Medicare Fee-for-Service beneficiaries undergoing a discharge appeal, who are experiencing chronic medical conditions requiring lifelong care management. It serves as an enhancement to the existing beneficiary appeals process. This program is not only a resource for Medicare beneficiaries, but extends support for their family members, caregivers and providers as active participants in the provision of health care delivery. So what services are offered by this program? The BCMP program will focus on these key care management support services:
- Discharge Planning and Care Coordination
- Healthcare Care Navigation
- Beneficiary Empowerment and Self Care
Please make note that the BCMP program is a referral-base program, initiated by your respective regional BFCC-QIO. If you or a family member have an active discharge appeal, we encourage you to contact the regional BFCC-QIO to discuss if you could benefit from this service. At your convenience, you may also access additional program information at: www.bcmpqio.org.
denial of coverage from a medicare advantage plan
If you have a Medicare Advantage plan, you have some additional Medicare rights. If you are concerned that you cannot get the care you need, you have the right to appeal to the Medicare Advantage plan. You can appeal things like denials for:
- Referrals to a specialist;
- Approval for tests (like x-rays or blood tests); and
- Payment of a bill.
The Medicare Advantage plan has information about how to start the appeal process. If you feel you may get worse by waiting too long, you can ask for an expedited appeal. This means the Medicare Advantage plan must make a decision about the appeal within three calendar days. If you need this faster review, ask your Medicare Advantage plan for an “expedited appeal.”
For additional information about a denial of coverage, call 1-800-MEDICARE.
kepro contact information
Kepro Region 1 – Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont
Appeal Helpline - 888-319-8452
Kepro Region 4 – Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
Appeal Helpline - 888-317-0751
Kepro Region 6 – Arkansas, Louisiana, New Mexico, Oklahoma, Texas
Appeal Helpline - 888-315-0636
Kepro Region 8 – Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming
Appeal Helpline - 888-317-0891
Kepro Region 10 – Alaska, Idaho, Oregon, Washington
Appeal Helpline - 888-305-6759
TTY for all areas: 711
For additional information about asking for medical records, please complete a Medical Record Request Form.
