CMS Medicare Specialist Appeals & Grievances Process 2

Question 1

What is an expedited appeal in Medicare, and when is it used?

Accepted Answer

A fast-track appeal used when standard timing could seriously jeopardize health or life

Answer

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?

Accepted Answer

14 calendar days

Answer

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?

Accepted Answer

Independent Review Entity (IRE)

Answer

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:

Accepted Answer

Medicare Appeals Council

Answer

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?

Accepted Answer

A request for expedited review by a Quality Improvement Organization when a beneficiary disagrees with a hospital discharge decision

Answer

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).

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Appeals & Grievances Process 2