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. You can continue your appeal if you still reside in a skilled nursing facility (SNF) or want further home health or comprehensive outpatient rehabilitation facility care.
If you are still residing in a skilled nursing facility or want further home health or comprehensive outpatient rehabilitation facility care:
- You can appeal the QIO's decision no later than 60 days after you received the original denial from the QIO. The QIO must issue a reconsideration decision as quickly as your health condition requires but no later than 14 days after receiving the request for reconsideration.
- If the QIO upholds its decision after reconsideration, you are responsible for the costs of continued care after the termination date indicated in the QIO decision. You can appeal to an Administrative Law Judge (ALJ), the Medicare Appeals Council (MAC), and then the Federal District Court.
- If you appeal and win at an upper level, the plan must reimburse the costs of any covered services that you already paid the provider.
If you no longer reside in a SNF or want reimbursement for care you’ve already gotten, you can file a standard reconsideration with your Medicare Advantage plan no later than 60 days from the date of the QIO notice.
If you would like to learn more about how to appeal to Medicare Advantage plans, please click here.