Free Medicare Peer Review Letter

Medicare carriers and fiscal intermediaries, both of which are private insurance organizations, process Medicare claims. Carriers process all Medicare Part B claims, such as claims submitted on your behalf for physician's services, certain outpatient hospital services (including emergency room visits), ambulances, diagnostic tests, laboratory services, certain preventive care services such as mammography and pap smear screening, outpatient therapy services, durable medical equipment and supplies, and home health care services not covered by Part A.

The Recipient of this letter might have questions or need additional information from you. Thus, you should include information about how you would like to be contacted.

If you suspect that your doctor, hospital or other health care provider is performing unnecessary or inappropriate services or is billing Medicare for services you did not receive, you should report such fraud or abuse immediately to the Medicare carrier or intermediary who handles your claims.

If the Medicare carrier or intermediary does NOT adequately respond to your letter reporting Medicare fraud or abuse, you may send this letter to: HHS - Tips, P.O. Box 23489, Washington, D.C. 20026.

If you prefer to make your complaint by telephone, the toll-free Hotline number is 1-800-447-8477. This number is staffed from 8:00 a.m. until 5:30 p.m. Eastern Standard Time, Monday through Friday. You should ONLY write or phone the Hotline if you have NOT received a satisfactory response from the Medicare carrier or intermediary.

Medicare carriers and fiscal intermediaries, both of which are private insurance organizations, process Medicare claims. Intermediaries process all Medicare Part A claims, such as claims submitted on your behalf by hospitals, skilled nursing facilities, home health agencies, and hospices.

Medicare is a health insurance program administered by the federal government for persons aged 65 or over, for certain disabled individuals under age 65, and for people of any age with permanent kidney failure needing dialysis or a transplant. Eligibility is NOT based on income or financial worth. Part A covers hospital care. Part B is optional and pays for physician and outpatient services. For information regarding application procedures or questions regarding Medicare, contact your local social security office or call its toll-free number (1-800-772-1213). The toll-free number is staffed from 7:00 a.m. to 7:00 p.m. every business day. The toll-free number for the hearing and speech impaired is 1-800-325-0778, which is also staffed from 7:00 a.m. to 7:00 p.m. every business day.

The phone number of your local Social Security Administration office is listed in your telephone directory under "Social Security Administration" or "U.S. Government." You must contact your local social security office to apply for Medicare benefits. If you have questions about your eligibility for either Medicare Part A or Medicare Part B, you can obtain additional information on the internet at www.medicare.gov or www.hcfa.gov.

Generally, Medicare Part A does not cover convenience items (e.g. telephones and televisions, private rooms, or private duty nurses) or custodial services (e.g. help with daily living activities such as bathing or getting dressed). Medicare Part B generally does not pay for most prescription drugs, routine physicals, services not related to treating an illness or injury, dental care or dentures, cosmetic surgery, routine foot care, hearing aids, eye examinations or eye glasses.

Do not confuse Medicare with Medicaid. Medicaid is a medical assistance program administered jointly by the federal and state government for needy, blind, and disabled persons. Medicaid services are provided by participating providers. Medical benefits and reimbursement formulas for Medicaid are established by each state.

Medicare is administered by the federal government, which contracts with private insurance companies for processing of payments to health care providers and patients. INTERMEDIARIES handle claims submitted on your behalf by hospitals, skilled nursing facilities, home health agencies, hospices, and other providers of Part A services. The insurance companies that process Part B claims are called CARRIERS.

The Peer Review Organization (PRO) is a group of practicing doctors and other health care professionals who are paid by the federal government to review the care provided to Medicare patients. Each state has a PRO which determines payment of claims based on whether the care is reasonable and necessary, is provided in the appropriate setting, and meets the standards of medical professional quality.

PRO's review Notices of Noncoverage issued by hospitals and review requests for reconsideration of PRO decisions. PRO's also investigate complaints about the quality of care provided by Medicare participants.

Generally, a Medicare beneficiary or his or her representative must be advised in writing when an item or service is not covered by Medicare. For example, a Notice of Noncoverage should be provided to a beneficiary who does not meet the age range or frequency guidelines for screening mammograms, pap smears, and colorectal cancer. However, Notices of Noncoverage are not required for items and services that are generally considered not to be covered by Medicare, such as routine physicals, screenings and custodial care.

If you think you are improperly refused admission to a hospital or that you are forced to leave a hospital too soon, ask for a written explanation of the decision. This explanation is called a Notice of Noncoverage. YOU MUST HAVE THIS "NOTICE OF NONCOVERAGE" IF YOU WANT TO REQUEST A REVIEW BY THE PEER REVIEW ORGANIZATION (PRO).

A written notice that further treatment in the hospital is not covered by Medicare must be provided to the patient before the patient must pay for services not covered by Medicare. If a written Notice of Noncoverage is not provided to the patient, then the PROVIDER of the noncovered services is held financially responsible. The patient does NOT have to leave the hospital, but, unless they request a review of the Notice of Noncoverage, he or she generally must pay for the services provided BEGINNING ON THE THIRD CALENDAR DAY AFTER RECEIPT OF THE NOTICE OF NONCOVERAGE. The time frame for appeals is limited, so note the DATE AND TIME OF DAY that the Notice of Noncoverage was received. As long as you request the PRO review by NOON OF THE FIRST WORK DAY AFTER YOU RECEIVE THE NOTICE OF NONCOVERAGE either by phone or in writing, you will NOT have to pay for noncovered hospital care until the PRO makes its decision.

If the PRO issues a denial notice, or if the notice indicates that the PRO agrees with the hospital's recommendation, then the patient must ask for a "reconsideration." However, since the PRO has already reviewed your case once, you MAY have to pay for at least one day of hospital care while the PRO completes its reconsideration.

The above-described process is called "immediate review." If you happen to miss a deadline for this immediate review, you can still request a review of the Notice of Noncoverage by following the instructions listed on the Notice of Noncoverage.

Medicare consists of two parts. Part A (hospital insurance) covers hospital care, limited post-hospital skilled nursing facility care, part-time home health services, and hospice care. If you are 65 years old or over, you can receive Medicare Part A insurance without having to pay a premium if you are currently receiving or eligible to receive but have not yet filed for either Social Security or Railroad Retirement benefits or if you or your spouse had Medicare-covered employment by the government. If you are under 65, you can receive Medicare Part A insurance without having to pay a premium if you have received either Social Security or Railroad Retirement benefits for twenty-four (24) months or if you are a kidney transplant or kidney dialysis patient.

Deductibles and coinsurance amounts must be paid by the Medicare beneficiary.

Medicare measures the amount of covered hospital care and skilled nursing care in benefit periods. A benefit period begins on the first day you receive care and terminates after you have been out of the hospital or skilled nursing facility and have not received care in any other facility for 60 consecutive days. Medicare does not limit the number of benefit periods any one beneficiary can have. Beneficiaries are entitled to a lifetime reserve of 150 days of in-patient services.

Medicare Part A covers 90 days of inpatient hospital care for each benefit period. If you need skilled nursing or rehabilitative services after a hospital stay and meet certain conditions, Medicare Part A helps pay for up to 100 days in a participating skilled nursing facility for each benefit period. For the first 20 days in a participating skilled nursing facility, Medicare pays for all approved charges. You must pay a coinsurance amount for the 21st day through the 100th day.

If you qualify, Medicare pays for all approved costs of covered home health care services. You will have to pay a 20% coinsurance charge for certain medical equipment, such as a wheelchair or a walker.

The terminally ill Medicare beneficiaries who select the hospice care benefit are not required to pay deductibles but are required to pay a limited amount for certain drugs and inpatient respite care.

This document provides a letter to request that Medicare reconsider its decision on a Part A claim. Providers of Part A services submit claims for their services directly to Medicare. The provider will charge you for any part of the Part A deductible that you have not met and any coinsurance payments that you owe.

You will receive a determination explaining the decision that Medicare has made on the claim. (If you have received a "Notice of Noncoverage," this is not an official determination. Ask your provider to submit your claim so that you can receive a determination from Medicare explaining the noncoverage of the claim.)

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have 60 days after receipt of the initial determination, which is presumed to be five days after the date of the initial determination notice, to request a reconsideration. (There are procedures to establish good cause for filing a late request for reconsideration.) The first step in the appeal process is to ask for a "reconsideration" of the decision. The initial determination contains the address and phone number of the organization to contact about your appeal.

You will receive a written response of the reconsideration that explains the reasons for the decision. If you disagree with the reconsideration of the decision, AND if the amount in question is $100 or more, then you have 60 days from the date you receive the reconsideration notice to request a hearing with an Administrative Law Judge.

If you are considering such a request, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a reconsideration by telephone. Contact your local social security office for more information.

Medicare consists of two parts. Part B (Supplemental Medical Insurance) covers physician's services, certain outpatient hospital services (including emergency room visits), ambulances, diagnostic tests, laboratory services, certain preventive care services such as mammography and pap smear screening, outpatient therapy services, durable medical equipment and supplies, and home health care services not covered by Part A.

Medicare Part B pays 80% of approved charges for most covered services. The beneficiary is responsible for paying a $100 deductible each calendar year as well as the remaining 20% of the Medicare approved charges. The beneficiary may have to pay additional charges if the doctor providing the care does not agree to Medicare's approved charges.

Medicare Part B is a voluntary program and is partially financed through monthly premiums, deductions, and coinsurance payments. The balance is funded by the federal government.

This document provides a letter to request that Medicare review its decision on a Part B claim. Doctors, suppliers, and other providers of Part B services submit claims directly to Medicare. The provider will charge you for any part of the Part B deductible that you have not met and any coinsurance payments that you owe.

A written notice, such as a Notice of Noncoverage, from your doctor is not an official Medicare determination that Medicare will not consider a particular service reasonable or necessary and will not pay for it. Ask your doctor to submit a claim for payment to the Medicare carrier to obtain an official Medicare decision.

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have the right to appeal the decision. The first step in the appeal process is to ask for a "review" of the decision. Many times the initial determination fails to sufficiently explain the reasons for the denial. By asking for a reconsideration or review, the basis for denial will be clarified.

Your appeal can be processed much more quickly if you include a copy of the notice(s) that you received about your claim. If you do not attach a copy of the "Explanation of Medicare Benefits" form to your appeal letter, you will need to describe the services, provide the name of the service provider, and indicate the date the services were provided.

This review must be requested by the patient in writing WITHIN SIX MONTHS after the date of the initial decision. (This period can be extended upon a showing of good cause.) You must request the review in writing and file it at an office of the carrier, the Social Security Administration, or the Health Care Financing Administration (HCFA) office. The address and phone number of the organization to contact regarding your appeal is contained on the notice informing you of the decision made on your request for payment.

You will receive a written response of the review explaining the reasons for the decision and advising you of your right to a hearing and how to request it. If you disagree with the review determination, AND if the amount in question is at least $100 but less then $500, then you have SIX MONTHS after the date of the review determination to request a hearing before the carrier's hearing officer. (This period can be extended upon a showing of good cause.) If you are considering requesting a hearing, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a review by telephone. Contact your local social security office for more information.

Peer Review Organizations (PRO's) are groups of practicing doctors and other health-care professionals who review the reasonableness, medical necessity, appropriateness, and quality of hospital care given to Medicare patients. PRO's primarily review complaints from beneficiaries and their representatives regarding Medicare Part A benefits. PRO's have the authority to deny payments if care is not medically necessary or not delivered in an appropriate setting.

PRO's process complaints in one of two ways: (1) concurrently -- while the patient is still in the medical facility receiving services; or (2) retrospectively -- after the patient has been discharged from the facility and is no longer receiving services. Whether the review is concurrent or retrospective, the timing of a PRO's review begins when a complaint is received in writing from a beneficiary or their representative and when the PRO has adequate information to begin the review (e.g. received medical records).

The PRO's must then acknowledge receipt of the complaint. This can be done either in writing or orally. For concurrent review, the PRO's must acknowledge receipt of the complaint within one full working day from receipt. The PRO's have five calendar days to acknowledge receipt for retrospective review.

Whether or not the reviewing PRO identifies any quality concerns during retrospective review, the PRO's completed review or notice must be sent to the medical provider within 15 calendar days after receipt of the medical records. Whether or not the reviewing PRO identifies any quality concerns during concurrent review, the PRO's completed review or notice must be completed and sent to the medical provider within one full working day after receipt of the medical records.

When a patient is admitted to a Medicare participating hospital, the patient receives a publication entitled "AN IMPORTANT MESSAGE FROM MEDICARE." It explains the patient's rights as a hospital patient and provides the name, address, and phone number of the PRO for that patient's state. Carefully read the description of the time frames in which you must take action depending upon various circumstances. Failure to make your appeal within the specified time frames may impact the portion of your hospital stay for which you will be responsible for paying.

1. The Medicare beneficiary should sign the letter.

2. If the Medicare beneficiary is unable to sign the letter, he/she should mark the signature line with an "X" and have two witnesses sign the letter. Alternatively, a legal representative of the beneficiary may sign the letter as long as evidence of the legal representative's authority is attached to the letter. For example, you could attach a power of attorney or appoint a legal representative by contacting the social security administration office. Contact an attorney for additional information regarding appointing a legal representative to act on behalf of the beneficiary. You should be aware that if a legal representative signs the letter, Medicare's response may still be sent to the beneficiary.

3. If applicable, attach a copy of the Notice of Noncoverage to this letter.

4. If applicable, attach any additional supporting documentation or notices you may have to this letter.

5. The Medicare beneficiary or the beneficiary's representative should keep a copy of the letter and any attachments for his or her records.

The letter should be signed by the Medicare beneficiary. However, if the Medicare beneficiary is unable to sign the letter, he or she should mark the signature line with an "X" and have two witnesses sign the letter.

Both witnesses must watch the Medicare beneficiary mark the signature line with an "X." However, the witnesses need not read the letter or know of its contents.

Each witness must sign his or her name on the lines provided below the Medicare beneficiary's signature line. Each witness should then review their printed name and address for accuracy.