For Professionals: Medicare Billing, Claims and Appeals

Are You Eligible for a Re-Review of Past Denied Medicare Claims?

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May 12, 2014

This short article provides a brief background on the Jimmo settlement followed by an overview of who is eligible for a re-review process of denied claims for skilled care, the timeline to apply, and a link for more information.

Background on the Jimmo Settlement Agreement
The Jimmo settlement of January 24, 2013 clarified that Medicare’s maintenance coverage for skilled nursing or therapy services does not depend on whether a beneficiary has improved or can improve. Instead, coverage depends on whether skilled care is needed to maintain a patient’s condition, slow his/her decline or prevent deterioration. This is an important clarification, especially for beneficiaries with chronic or long-term conditions. In the past, Medicare’s contractors, skilled nursing facilities and home health agencies seemingly systematically and erroneously denied many beneficiaries skilled care because beneficiaries did not improve or could not show “improvement potential.”

While the Centers for Medicare and Medicaid Services denies imposing an “improvement standard” as a rule-of-thumb, they have revised, pursuant to the Jimmo settlement, the Medicare Policy Manuals to clarify that improvement is not required for Medicare to cover skilled services necessary for the beneficiary to maintain function or prevent or slow deterioration. Per the Jimmo Settlement, CMS is now also implementing an Education Campaign to ensure that Medicare determinations for skilled nursing facility and home health benefits, and outpatient therapy are made correctly.

Also pursuant to the settlement, certain beneficiaries who were wrongly denied maintenance coverage now have an opportunity to have their claims re-reviewed. The process is not automatic. Beneficiaries who want to take advantage of the re-review process must fill out and submit a form, known as a Request for Re-Review (pdf).

Who is Eligible for the Re-Review Process?
You may be eligible for re-review if you:

  • Received skilled nursing or therapy services in a skilled nursing facility, home health setting, or outpatient therapy setting, and
  • Received a partial or full denial of Medicare coverage for those services based on your lack of improvement or potential to improve, and
  • The denial became final and non-appealable (meaning Medicare denied your claim and it is not eligible for further appeal) on or after January 18, 2011 and before January 23, 2014.

This last statement means that the disputed service(s) could have happened before that date. Any denied claims that were “alive” on or after January 18, 2011 and became “final” sometime on or before January 23, 2014 are eligible for the re-review process.

If you have a denied claim that was still “alive” (meaning you still had the option of going further along in the appeals process) after January 23, 2014, it is not eligible for the re-review. In this case, it should go through the normal Medicare administrative appeals process. When taken to the next level of review/appeal, it will be reviewed under the newly revised manual provisions.

What is the timeline for the re-review process?
There are 2 different timelines for filling out the form and applying for a re-review:

  • If your maintenance care denial became final and non-appealable on or after January 18, 2011 through January 24, 2013, your request for review must be postmarked no later than July 23, 2014.
  • If your maintenance care denial became final and non-appealable on or after January 25, 2013 through January 23, 2014, your request for review must be postmarked no later than January 23, 2015.

Directions on how to apply for the re-review are explained on the Request for Re-Review form (pdf) listed on the Centers for Medicare and Medicaid Services (CMS) website.

More information
For more information, see CMS’ webpage: Important News for Beneficiaries: Jimmo Re-Review Information. Also, contact your local Health Insurance Counseling and Advocacy Program (HICAP) if you have questions and/or would like assistance with the re-review process.

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