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Appeal and reconsideration processes, Preferred Care Partners - 2021 UnitedHealthcare Administrative Guide

MA hospital discharge appeal rights protocol

MA members have the right to appeal their hospital discharge to a Beneficiary Family Centered Care Quality Improvement Organization (BFCC-QIO) for immediate review. The BFCC-QIO for Florida is KEPRO.

The BFCC-QIO notifies the facility and Preferred Care of an appeal and:

  • Preferred Care facility onsite concurrent review staff completes the Detailed Notice of Discharge (DNOD) and delivers it to the MA member or their representative as soon as possible but no later than 12 p.m. ET the day after the BFCC-QIO notification of the appeal is received. The facility faxes a copy of the DNOD to the BFCC- QIO; or
  • When no Preferred Care facility onsite staff is available, the facility completes the DNOD and delivers it to the MA member or their representative as soon as possible but no later than 12 p.m. ET the day after the BFCC-QIO notification of the appeal is received. The facility faxes a copy of the DNOD to the BFCC-QIO and Preferred Care.

Facility (SNF, HHA, CORF) notice of Medicare Non-Coverage (NOMNC) protocol

CMS requires SNFs, HHAs, and CORFs deliver the NOMNC-required notice to members at least 2 calendar days before termination of skilled nursing care, home health care or comprehensive rehabilitation facility services. If a member’s services are expected to be fewer than 2 calendar days in duration, deliver the notice at the time of admission or commencement of services in a non-institutional setting. In a non-institutional setting, if the span of time between services exceeds 2 calendar days, give the notice no later than the next to last time services are furnished.

Delivery of notice is valid only upon signature and date of the member or their authorized representative if the member is incompetent. You must use the most current version of the standard CMS-approved form titled, “Notice of Medicare Non- Coverage” (NOMNC). You may find the standardized form and instructions on the CMS website. You may also contact KEPRO the BFCC-QIO for Florida at kepro.com for more information. You may not change the NOMNC notification text.

Clinical appeals: standard and expedited

To appeal an adverse decision (a decision to deny the authorization of a service or procedure because the service is determined not to be medically necessary or appropriate) on behalf of a member, submit a formal letter outlining the issues. Include supporting documentation. The denial letter you received provides you with the filing deadlines and the address to use to submit the appeal.

Medicare guidance allows the servicing care provider to submit an appeal on behalf of the member.

When we make a final decision, we notify you by mail. If we overturn the original determination, the service will be authorized. If we uphold the original denial determination, there is no additional action.

Benefit summaries

For information on benefits, go to mypreferredcareprovider.com > Provider Resources > Summary of Benefits.