SNF IRF LTAC > Denial and Appeals Process
Unable to Provide Prior Approval for Initial Request cases that do not meet medical necessity on initial nurse review will be sent to a second level physician for review and determination. If a potential adverse determination is made by an eviCore physician, they will reach out to the requesting facility and a Peer to Peer Review will be offered.
Peer to Peer (P2P) must be requested within 1 business day, or additional clinical information that supports medical necessity must be received within 1 business day, or the determination is final and the case will be closed. Note: P2P must occur within 1 business day or a denial letter will be issued.
If the P2P process does not result in a reversal of the recommendation of denial, eviCore will issue a denial letter. The physician reviewer may suggest an alternate level of care and/or the appeals process.
Once a service has been denied, members and providers must file an appeal to have the request reviewed again.
Medicaid or Commercial Members requesting to appeal a denial for initial PAC services should follow the instructions provided on the denial letter. Appeal requests must be submitted to eviCore via phone at 800-835-7064 (Monday through Friday, 8 a.m. - 6 p.m. EST) or faxed to 866-699-8128.
Medicare Members may request an appeal of a denial for initial PAC services by following the instructions provided in the denial letter. Providers should follow the process outlined in the Dispute Resolution for Medicare chapter.
Unable to Extend Services Cases that do not meet Medical Necessity on concurrent nurse review will be sent to a 2nd level physician for review and determination.
If a member appeals the end-of-stay decision through Island Peer Review Organization (IPRO), the SNF is responsible for sending the medical records to IPRO by the end of the day on which they were requested. IPRO is open seven days a week to take appeal information.
|Inpatient Rehabilitation Facility (IRF)
- Peer to Peer (P2P) must be requested within 1 business day or a denial letter will be issued. Or, additional clinical information that supports medical necessity must be received within 1 business day. If not, the determination is final and the case will be closed.
|SNF Date Extensions
(Concurrent review requests)
|The Notice of Medicare Non-Coverage (NOMNC) will be issued no later than 2 calendar days prior to the discontinuation of coverage. The third calendar day will not be covered unless the decision is overturned or the NONMC is withdrawn.
- P2P must be requested and occur within the 2 calendar day timeframe.
- If P2P does not occur or if the decision is upheld, the member is responsible for paying for the continued stay if they choose not to discharge on the 3rd calendar day.
|Member Appeals Process
- Medicaid and Commercial members requesting to appeal the decision to end skilled care in a PAC facility (SNF, IRF or LTAC) or HHC services should contact eviCore via phone at 800-835-7064 (Monday through Friday, 8 a.m. – 6 p.m. EST) or fax to 866-699-8128.
- Medicare members requesting to appeal the decision to end skilled care in a SNF facility or HHC services should follow the QIO process as outlined on the NOMNC. Providers should follow the process in the Dispute Resolution for Medicare chapter.
- Medicare members may request an appeal of a denial based on the decision to end skilled care for concurrent IRF services by following the instructions provided in the denial letter. Providers should follow the process in the Dispute Resolution for Medicare chapter.
|Reconsiderations Process (Commercial and Medicaid only)
- A Reconsideration is a post-denial, pre-appeal opportunity to provide additional clinical information.
- Reconsideration must be requested within 14 days of the Initial Denial Date.
- Peer to peer (P2P) requests can be made via verbal or written request.
- P2P is conducted with the referring MD and one of eviCore’s Medical Directors.
- P2P results in either a Reversal or an Uphold of the original decision.
- The DME Supplier and the Member are notified via mail and fax.
| Appeals Process (Medicare, Medicaid and Commercial)
- 1st level Commercial and Medicaid appeals will be handled by eviCore.
- Medicaid or Commercial members requesting to appeal a denial should follow the instructions provided on the denial letter. Appeal requests must be submitted to eviCore via phone at 800-835-7064 (Monday through Friday, 8 a.m. - 6 p.m. EST) or faxed to 866-699-8128.
- Medicare appeals will be handled by EmblemHealth.
- Medicare members may request an appeal of a denial by following the instructions provided in the denial letter. Providers should follow the process in the Dispute Resolution for Medicare chapter.
Turn-Around Time after an Appeal has been requested by the member:
- Expedited – up to 72 hours
- Standard – up to 30 days
Glossary terms found on this page:
A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.
A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.