Appeal and reconsideration processes, Preferred Care Network (formerly Medica HealthCare) - 2022 UnitedHealthcare Administrative Guide
MA hospital discharge appeal rights protocol
MA members have the statutory 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 Network of an appeal and:
Preferred Care Network facility onsite concurrent review staff completes the Detailed Notice of Discharge (DNOD) and delivers it to the member or their representative as soon as possible but no later than 12 p.m. ET of the day after the BFCC- QIO notification of the appeal is received. The facility faxes a copy of the DNOD to the BFCC-QIO.
When there are not any Preferred Care Network facility onsite staff, the facility completes the DNOD, and delivers the DNOD to the member or their representative as soon as possible but no later than 12 p.m. ET of 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 Network.
Facility (SNF, HHA, CORF) Notice of Medicare Non-Coverage (NOMNC) protocol
CMS requires SNFs, home health agencies (HHAs) and comprehensive outpatient rehabilitation facilities (CORFs) to deliver the NOMNC notice to members at least 2 calendar days prior to termination of skilled nursing care, home health care or comprehensive rehabilitation facility services. If the member’s services are expected to be fewer than 2 calendar days in duration, the notice should be delivered 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, the notice should be given no later than the next to last time services are furnished.
Delivery of notice is valid only upon signature and date of member or member’s authorized representative if the member is incompetent. You must use the most current version of the standard CMS approved notice entitled Notice of Medicare Non- Coverage (NOMNC) form. The standardized form and instructions regarding the NOMNC are on the CMS website or contact KEPRO, the BFCC-QIO for Florida, at keproqio.com. The NOMNC notification text may not be modified.
Clinical appeals: Standard and expedited
To appeal an adverse decision (a decision to deny authorization of a service or procedure because the service is determined not to be medically necessary or appropriate) on behalf of a member, you must submit a formal letter outlining the issues and submit supporting documentation. The denial letter you received provides you with filing deadlines and the address to submit the appeal. Medicare guidance allows the servicing health care provider to submit an appeal on behalf of the member.
When we make the final decision, we notify you via mail. If the decision is to overturn the original determination, we will authorize the service. If the decision is to uphold the original denial determination, there will be no further action for you to undertake.
For information on benefit plans, visit pcnhealth.com > Members.