CMS Medicare Specialist Appeals & Grievances Process 2 — Questions and Answers
Question 1: What is an expedited appeal in Medicare, and when is it used?
- An appeal filed online to speed processing
- A fast-track appeal used when standard timing could seriously jeopardize health or life (Correct answer)
- An appeal that skips the MAC level
- An appeal available only for Part D denials
Correct answer: A fast-track appeal used when standard timing could seriously jeopardize health or life
An expedited appeal allows rapid review within 72 hours for Medicare Advantage when the standard timeline could seriously harm a beneficiary's health, life, or ability to regain maximum function.
Question 2: For a Medicare Advantage organization determination, what is the standard timeframe for the plan to issue a decision on a prior authorization request?
- 24 hours
- 14 calendar days (Correct answer)
- 3 business days
- 30 calendar days
Correct answer: 14 calendar days
Medicare Advantage plans must issue standard prior authorization decisions within 14 calendar days for medical services.
Question 3: Which entity handles the second level of appeal for Medicare Advantage plan denials?
- Medicare Administrative Contractor
- Qualified Independent Contractor (QIC)
- Independent Review Entity (IRE) (Correct answer)
- Medicare Appeals Council
Correct answer: Independent Review Entity (IRE)
For Medicare Advantage appeals, the second level reconsideration is conducted by an Independent Review Entity (IRE) contracted by CMS, not a QIC.
Question 4: A Medicare beneficiary disagrees with an ALJ decision. The next appeal level is:
- Federal District Court
- Qualified Independent Contractor
- Medicare Appeals Council (Correct answer)
- State Insurance Commissioner
Correct answer: Medicare Appeals Council
After an unfavorable ALJ decision, the beneficiary may appeal to the Medicare Appeals Council (Departmental Appeals Board) before seeking judicial review.
Question 5: What is a fast-track appeal related to discharge from a hospital?
- A complaint filed with the state health department
- A request for expedited review by a Quality Improvement Organization when a beneficiary disagrees with a hospital discharge decision (Correct answer)
- A billing dispute sent to the MAC
- An ALJ hearing for inpatient stays
Correct answer: A request for expedited review by a Quality Improvement Organization when a beneficiary disagrees with a hospital discharge decision
When a beneficiary believes they are being discharged too soon, they can request an expedited review from the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
Question 6: Under Medicare Part D, how many days does a beneficiary have to file an appeal after receiving a coverage denial notice?
- 30 days
- 60 days (Correct answer)
- 90 days
- 180 days
Correct answer: 60 days
Beneficiaries have 60 days from the date of the coverage denial notice to file a redetermination appeal with their Part D plan.
CMS Medicare Specialist Appeals & Grievances Process 2
What is an expedited appeal in Medicare, and when is it used?