Expedited Appeal Review for Termination of Fee-For-Service Medicare Coverage

Medicare enrollees must receive a notice at least two days before planned termination of coverage of their Medicare-covered comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice or skilled nursing facility (SNF) services end.

There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Non-Coverage) that the provider will deliver whenever a beneficiary’s Medicare coverage of current items and/or services is ending. Note that beneficiaries receiving skilled nursing services in swing bed settings—both PPS and critical access hospitals—should get this notice instead of an Important Message from Medicare. The phone number for the QIO that should be included in this notice is 1-800-725-8339. The second is a detailed notice called a Detailed Explanation of Non-Coverage that the provider will deliver to the beneficiary and the appropriate Quality Improvement Organization (QIO) only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end.

Expedited appeals will be conducted by TMF Health Quality Institute's Review & Compliance Department as part of TMF's responsibilities as the Medicare QIO for Texas. Appeals will require that a copy of the beneficiary's medical record, generic, and detailed notice be provided to TMF no later than close of business of the day the request for an appeal was made.

For additional information about this expedited review process, please visit CMS’s website.

TMF Appeal Contact Information

TMF Health Quality Institute
Bridgepoint I, Suite 300
5918 West Courtyard Drive
Austin, TX 78730-5036

Beneficiary Appeal Line Only: 1-800-725-8339

Provider Contact Line Only: 512-329-6610

Fax: 1-800-210-9317

TTY: 1-877-486-2048

Bridgepoint I Suite 300 | 5918 West Courtyard Drive | Austin, Texas 78730-5036 | Phone 1-800-725-9216 | Fax 512-327-7159 | Email TexasQIO@tmf.org
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