O-7-131 Escalation of Medicare Appeal Requests

🎯 PURPOSE

To describe the process for escalating Medicare appeals.

A client that is a Medicare Beneficiary has the right to appeal the decision the agency made to end home health services. Once the request to appeal the decision is made, it goes to a Quality Improvement Organization (QIO) authorized by Medicare. The current QIO is called Commence Health.

The QIO will contact the branch location to request additional documentation, often by fax. These records must be submitted by the END of the SAME business day they are requested.

🔄 PROCESS

Responsible Position: Clinical Supervisor/Designee

1. If a client expresses a concern to a clinician of the intent to appeal the decision the agency made to end home health services, the clinician should escalate the concern to a Clinical Supervisor/designee.
2. The Clinical Supervisor should investigate the situation, interview the client and clinician to determine the reason the client wishes to appeal the decision, and the reason we determined for the agency discharge. The Clinical Supervisor will provide guidance and follow-up as appropriate.
   1. Does the service(s) need to continue? Doe we need to contact the provider and pursue an order for continued care?
   2. Was the Notice of Medicare Non-Coverage given and when?
   3. When is the Discharge from Agency scheduled for?
   4. Has the clinician issued the Detailed Explanation of Non-Coverage?
3. Ensure the Notice of Medicare Non-Coverage is completed and back to the office the same day it was given.
4. Instruct the clinician to issue the Detailed Explanation of Non-Coverage (this must be done same day as the client's appeal date).
5. Notify the Parent Compliance Team (Vice President of Nursing/Compliance Officer and Compliance Manager), Area Manager and Administrative Specialist that they are expecting a client to appeal their Medicare discharge.

Responsible Position: Administrative Specialist

1. Identify the Medicare Appeal Notifications Request for additional records as an urgent situation that requires timely action. Typically, these are received by fax notification and often seen by the person responsible for managing the incoming fax, but could also be requested through a phone call.

   1. Example:

      

2. Once the request is received by the branch location, immediately escalate the request to the Area Manager.

Responsible Position: Area Manager/Designee

1. The Area Manager should notify the Parent Compliance Team (Vice President of Nursing/Compliance Officer & Compliance Manager) immediately for further guidance.
   1. Attach the Medicare Appeal Notification Request form in the email.

Responsible Position: Parent/Corporate

1. The Parent Compliance Team will compile the records needed for the appeal request and send to Commence Health.
2. The Parent Compliance Team will communicate and coordinate with the location if additional information or actions are needed as appropriate.

📅 Effective: 04/08/2025  | 🛠️ Revised: 09/08/2026 |  ✅ Approved: RE