Post Test - Appeals

The statement is true because if an initial determination is a denial, it means that the request or application has been rejected. In such cases, the individual has the right to appeal the decision. The denial notice serves as a formal communication that informs the individual about the denial and also provides information about their appeal rights. These appeal rights allow the individual to challenge the denial and present their case for reconsideration.

The statement is true because according to the given information, in Part C organization determination, the plan has the option to request a 14 calendar-day extension if it is in the best interest of the member. This means that if the plan believes that taking extra time will result in a more accurate and fair determination, they can request an extension.

In order to ensure that a member has expedited grievance rights, a written notice must be sent. This written notice serves as a formal communication to inform the member about a specific issue or situation. By providing a written notice, the member can be informed in a clear and documented manner, allowing them to understand the grievance process and exercise their rights effectively.

The acronym IRE stands for Independent Review Entity. This term refers to an organization or entity that is responsible for conducting impartial and unbiased reviews or assessments. These reviews are typically carried out to ensure compliance with regulations, standards, or guidelines. An IRE plays a crucial role in providing an objective evaluation of processes, procedures, or decisions, helping to maintain transparency and accountability within an organization or industry.

The acronym NOMNC stands for Notice of Medicare Non-Coverage. This notice is given to Medicare beneficiaries to inform them that a particular service or treatment will no longer be covered by Medicare. It is an important communication tool that allows beneficiaries to understand their options and make informed decisions about their healthcare. The other option, Notice of Medicaid Coverage, is incorrect as it does not accurately represent the meaning of the acronym NOMNC.

When terminating SNF (Skilled Nursing Facility), Home Health, and CORF (Comprehensive Outpatient Rehabilitation Facility) services, it is required for the provider to issue a NOMNC (Notice of Medicare Non-Coverage) within 2 calendar days of terminating the services. This notice informs the patient of the end of Medicare coverage for the specific services and allows them to request a review if they disagree with the decision. Therefore, the statement that the provider must issue NOMNC within 2 calendar days of termination of services is true.

The acronym NDMC stands for Notice of Denial of Medical Coverage. This means that when an individual's request for medical coverage is denied, they will receive a notice informing them of this denial. This notice serves as a formal communication indicating that their request for medical coverage has been turned down.

According to CMS requirements, if a healthcare provider indicates that applying the standard timeframe for a request would jeopardize the member's health, a plan must automatically handle an expedited request. This means that the plan must prioritize and expedite the request to ensure the member's health is not compromised. Therefore, the statement is true.

The member has the option to file an appeal within 60 days at the first level of the appeals process. This timeframe allows the member to review the decision and gather any necessary information or evidence to support their appeal. Filing within this timeframe ensures that the appeal is considered and processed in a timely manner, allowing for a fair and efficient resolution to the member's concerns or grievances.

When the Medicare benefit is exhausted, a NOMNC (Notice of Medicare Non-Coverage) is not issued. Instead, a NDMC (Notice of Discharge or Medicare Certification) must be issued. This means that the statement "A NOMNC is not to be issued when the Medicare benefit is exhausted. A NDMC must be issued instead" is true.

The statement is true because according to the given information, if a member does not have an appointed representative, the termination of inpatient hospital services must be delivered in person. This means that the member themselves must be present to receive the notification of termination.

If the plan upholds or agrees with the denial decision, it means that the plan supports the decision to deny coverage for certain services. In this case, the member is responsible for paying for those services starting from the date when the decision was made. Therefore, the statement "True" is correct because it accurately reflects the situation described.

Members can request an expedited grievance if they disagree with the 14-day extension.

On the termination of SNF, Home Health, and CORF services, all of the following statements are true. The member has the option to request a fast track appeal by telephone or in writing to the QIO. This request must be made by no later than noon of the day after the receipt of the NOMNC (Notice of Medicare Non-Coverage).

The correct answer is "All of the above" because CMS requirements state that written notices must include appeal rights, both expedited and standard, as well as the member's right to present evidence in writing and in person. This means that all three options mentioned in the question are required to be included in the written notices according to CMS requirements.