CMS Medicare Specialist Appeals & Dispute Resolution 2

Question 1

What is an 'expedited appeal' in the Medicare Advantage context, and when is it available?

Accepted 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

Answer

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?

Accepted Answer

OMHA administers ALJ hearings at the third level of the Medicare appeals process

Answer

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)?

Accepted Answer

The written decision issued by the MAC after completing a first-level redetermination appeal

Answer

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?

Accepted Answer

Request a coverage determination from the Part D plan

Answer

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?

Accepted Answer

The independent organization that conducts second-level reconsiderations of Part D coverage denials

Answer

The IRE performs the second-level reconsideration for Part D appeals, similar to the QIC's role in Part A/B appeals.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Appeals & Dispute Resolution 2