CMS Medicare Specialist Appeals & Dispute Resolution 2 — Questions and Answers
Question 1: What is an 'expedited appeal' in the Medicare Advantage context, and when is it available?
- A faster appeal decided within 72 hours when the standard timeframe could seriously jeopardize the beneficiary's health or ability to regain maximum function (Correct answer)
- An appeal filed within 24 hours of a denial for any reason
- A special appeal available only to inpatient hospital stays
- An appeal that bypasses the plan and goes directly to a QIC
Correct answer: A faster appeal decided within 72 hours when the standard timeframe could seriously jeopardize the beneficiary's health or ability to regain maximum function
Expedited appeals in MA plans must be decided within 72 hours when applying the standard 14-day timeframe would seriously jeopardize the enrollee's health.
Question 2: What is the role of the Office of Medicare Hearings and Appeals (OMHA) in the Medicare appeal process?
- OMHA administers ALJ hearings at the third level of the Medicare appeals process (Correct answer)
- OMHA conducts redeterminations at the first level of appeal
- OMHA is responsible for QIC reconsiderations at the second level
- OMHA issues final Medicare policy decisions binding on all parties
Correct answer: OMHA administers ALJ hearings at the third level of the Medicare appeals process
OMHA is the HHS component that manages ALJ hearings, which constitute the third level of the Medicare Part A/B/C/D appeals process.
Question 3: What is a 'Medicare Redetermination Notice' (MRN)?
- The written decision issued by the MAC after completing a first-level redetermination appeal (Correct answer)
- A notice sent by CMS when a beneficiary's Medicare eligibility is changed
- A document listing all covered services for the upcoming year
- A form a provider completes to request a claim correction
Correct answer: The written decision issued by the MAC after completing a first-level redetermination appeal
The MRN is the official written notice the MAC sends to inform all parties of the outcome of the redetermination at the first appeal level.
Question 4: Under Medicare Part D, what is the first step a beneficiary must take to appeal a coverage denial for a prescription drug?
- Request a coverage determination from the Part D plan (Correct answer)
- File a complaint directly with CMS
- Submit an appeal to the QIC
- Contact their state pharmacy assistance program
Correct answer: Request a coverage determination from the Part D plan
For Part D, the first step is requesting a coverage determination (including an exception request) from the Part D plan before any formal appeal.
Question 5: What is an Independent Review Entity (IRE) in the context of Medicare Part D appeals?
- The independent organization that conducts second-level reconsiderations of Part D coverage denials (Correct answer)
- A CMS contractor that audits Part D plan compliance
- An entity that conducts ALJ hearings for prescription drug disputes
- A third-party organization that reviews Part D formulary decisions annually
Correct answer: The independent organization that conducts second-level reconsiderations of Part D coverage denials
The IRE performs the second-level reconsideration for Part D appeals, similar to the QIC's role in Part A/B appeals.
Question 6: What is the 'binding nature' limitation of an ALJ decision in the Medicare appeals process?
- ALJ decisions are binding on all parties unless appealed to the Medicare Appeals Council or federal court (Correct answer)
- ALJ decisions are advisory only and not binding on CMS
- ALJ decisions bind the beneficiary but not the MAC or CMS
- ALJ decisions are binding only if the amount in controversy exceeds $10,000
Correct answer: ALJ decisions are binding on all parties unless appealed to the Medicare Appeals Council or federal court
ALJ decisions are binding on all parties to the appeal, but any party — including CMS — may further appeal to the Medicare Appeals Council.
CMS Medicare Specialist Appeals & Dispute Resolution 2
What is an 'expedited appeal' in the Medicare Advantage context, and when is it available?