Expedited Reviews Overview
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Advantage Organizations (MAOs) and participating providers promptly address all member concerns and complaints that are brought to their attention either orally or in writing. CMS also requires that MAOs have a process in place for expedited reviews of time-sensitive issues. Time-sensitive issues are defined as:
- Situations where waiting 7 to 14 days for an initial determination, or 30 days for a service reconsideration, could seriously jeopardize the life and health of the member or the member's ability to regain maximum function
All requests for service must be promptly reviewed to determine whether the request meets the established criteria. Requests for services that meet established criteria must be reviewed and resolved with 72 hours of receipt. The 72-hour time frame includes weekends and holidays and begins upon receipt, even if additional information is needed.
There are two types of expedited reviews:
- Expedited organization determination (EOD)
- An EOD is a decision to authorize or deny a time-sensitive service that meets the criteria for an expedited review.
- This type of expedited review is delegated to participating physician groups (PPGs) and monthly tracking logs are required. The plan does not delegate this responsibility to direct network physicians. Refer to the Expedited Organization Determination Process discussion for additional information.
- Expedited appeal
- An expedited appeal is a time-sensitive service appeal that meets the criteria for an expedited review.
- This type is not delegated to participating providers. Refer to the Expedited Appeals Process discussion below for additional information.
Criteria for Expedited Review
Requests that meet the criteria for an expedited review are:
- Requests by a participating provider for a time-sensitive determination.
- Requests for continued rehabilitation hospital stay.
- Requests for continued skilled nursing facility (SNF) stay, even if the member has reached the maximum limit.
- Requests for continued home health services.
- First requests for physical therapy within four months of a cerebrovascular accident (CVA), head injury or surgery, or other acute trauma.
- Requests for continued physical therapy within six months of a CVA, head injury or surgery, or other acute trauma.
- First requests for physical therapy within four months of a major joint surgery (for example, hip or total knee).
- Requests for continued physical therapy within six months of a major joint surgery.
- Requests for medication, chemotherapy, radiation therapy, or proposed surgical treatment of a known malignancy.
- Requests for proposed AIDS therapy.
- Requests for proposed experimental treatment for a terminal patient.
- Requests concerning a refusal by the provider to proceed with a scheduled service or test because the participating provider failed to obtain an authorization for a service that was scheduled (for example, surgery scheduled, but no authorization provided for the surgery). This applies to requests for referrals that have already been submitted.
- Requests for service concerning any life- or limb-threatening condition.
If the member complains of severe pain, consider requesting an EOD by determining whether delaying care could seriously jeopardize the life or health of the member or the member's ability to regain function.
An EOD must be provided when a participating provider requests an expedited review or supports the member's request, and indicates that applying the standard time frame could seriously jeopardize the life or health of the member or the member's ability to regain maximum function.
14-Day Extension for Expedited Appeals
An extension of up to 14 calendar days is permitted for a 72-hour appeal only if the extension of time benefits the member. Examples of this are a member needing time to provide the plan with additional information or a member in need of having additional diagnostic tests completed.
The plan makes a decision on an expedited appeal and notifies the member within 72 hours of receipt of the request. If the plan's decision, in whole or in part, is not in the member's favor, the plan automatically forwards the appeal request to CMS contractor, MAXIMUS Federal Services, as expeditiously as the member's health requires, but not later than 24 hours after the decision. If the plan fails to provide the member with the results of its reconsideration within the time frames specified above, this failure constitutes an adverse determination and the plan must submit the file to Maximus Federal Services within 24 hours. The plan must concurrently notify the member in writing that the case file was forwarded to MAXIMUS.
Fax Requests for Expedited Appeals
Fax written requests to the Medicare Advantage Appeals and Grievance Department.
- If a member is in a hospital or skilled nursing facility (SNF), the member may request assistance by faxing a written appeal to the plan.
- The time frame for reviewing standard or expedited appeals does not begin until the plan of the participating physician group (PPG) receives the appeal.
Oral Requests for Expedited Appeals
Oral requests from members for expedited appeals must be documented in writing. The 72-hour time frame begins on the date and the time the request is received orally or in writing, regardless of weekends or holidays, and regardless of whether the MAO participating provider receives the request. Any delay in forwarding such requests could result in non-compliance with CMS expedited appeal requirements.
For additional information regarding documentation of oral requests for expedited appeals, contact the Medicare Programs Member Services Department.
Health plans are allowed 30 days to process a standard service appeal. In some cases the member has the right to an expedited, 72-hour appeal. The member can receive an expedited appeal if his or her health or ability to regain maximum function could seriously be harmed by waiting for a standard service appeal, which may take up to 30 days. If the request is made or supported by a physician, the plan must grant the expedited appeal request if the physician indicates that the life or health of the member, or the member's ability to regain maximum function, could be seriously jeopardized by applying the standard time frame in processing the appeal request. If a member requests an expedited appeal, the plan evaluates the member's request and medical condition to determine whether the appeal qualifies for an expedited, 72-hour appeal. If not, the appeal is processed within 30 days.
If a member misses the noon deadline to file for immediate quality improvement organization (QIO) review of an inpatient hospital discharge, the member may request an expedited reconsideration with the plan. The member must specifically state that an expedited appeal or a 72-hour appeal is being requested and that the member believes his or her health could be seriously harmed by waiting for the standard appeal to be resolved.
If the plan denies a request for an expedited appeal, it must automatically transfer the request to the standard appeal process and then make its determination as expeditiously as the member's health condition requires, but no later than within 30 calendar days from the date the plan received the request for expedited appeal.
The plan does not delegate member grievances or appeals. All member grievances and appeals (standard and expedited) should be forwarded immediately to the Medicare Advantage Appeals and Grievances Department.
The plan prefers receiving appeals and grievances by fax. This enables the plan to receive, process and resolve the member's issue quickly in accordance with state and federal timeliness requirements.
The plan must also provide the member with prompt oral notice of the denial of the request for an expedited appeal and the member's rights, and subsequently mail to the member within three calendar days of the oral notification, a written letter that:
- Explains that the plan automatically transfers and process the request using the 30-day time frame for standard reconsiderations.
- Informs the member of the right to file an expedited grievance if he or she disagrees with the organization's decision not to expedite the reconsideration.
- Informs the member of the right to resubmit a request for an expedited reconsideration and that if the member gets any physician's support indicating that applying the standard time frame for making a determination could seriously jeopardize the member's life, health or ability to regain maximum function, the request is expedited automatically.
- Provides instructions about the grievance process and its time frames.
The plan and participating providers submitting expedited appeal requests must be prepared to re-submit materials if they are inadvertently sent to the wrong review entity. If a QIO or the independent review entity (IRE) that processes reconsiderations receives a request for an expedited review after the review deadline, it must notify the plan by telephone, so that the applicable appeals process can continue expeditiously. Neither QIOs nor the IRE is responsible for forwarding misdirected records to the appropriate office, so the plan and participating providers submitting expedited appeal requests must be prepared to resubmit the requested information to the correct office, or contact the member to initiate an expedited appeal if the member is filing an untimely fast-track appeal.