Appealing at upper levels if you have Original Medicare and your home health agency, skilled nursing facility, hospice agency, or comprehensive outpatient rehabilitation facility wants to end your care
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Last Update: July 09, 2012
If your appeal to the Quality Improvement Organization (QIO) was denied but you and/or your doctor feel that continued care is medically necessary, you can continue to appeal. Your doctor or other health care provider cannot bill you until the next appeal review entity makes its decision. The next appeal entity is called the Qualified Independent Contractor (QIC).
Requesting an Expedited Reconsideration
- To request an expedited reconsideration of the QIO's decision, you have to contact another group called a Qualified Independent Contractor (QIC). You should contact the QIC no later than noon the next calendar day after you receive the QIO's initial denial.
- The QIC must issue a reconsideration decision no later than 72 hours after receiving the request for reconsideration.
- If the QIC misses the deadline, it must notify you that you have the right to take the case to further levels of appeal.
- The next step after the QIC appeal is the Administrative Law Judge or ALJ appeal.
If you meet the deadline for an expedited reconsideration with the QIC, your doctor or other health care provider cannot bill you for continued care until the QIC makes its decision. If the QIC upholds the QIO denial, your provider can bill you for the cost of care after the date and time indicated on the NOMNC to leave and/or stop getting care.
If you miss the deadline for expedited reconsideration, you may request a standard reconsideration with the QIC within 180 days of the QIO decision. The QIC has 60 days to make its decision.
- If the QIC upholds the QIO's denial after reconsideration, appeal to an Administrative Law Judge (ALJ), the Medicare Appeals Council (MAC), and then the Federal District Court.
- You are responsible for the costs of continued care after the termination date indicated in the QIO decision.
- If you appeal and win at an upper level, the provider must reimburse the costs of any covered services that you already paid the provider.