Denied by Medicare? Class action suit allows a redetermination of benefits.

By admin

Many of my clients have gone from the hospital to a rehab facility for a 100 days Medicare stay only to learn after day 21, 31, 43 or so on that Medicare coverage is ending because they are no longer improving, or have “reached a plateau” in progress. This meant they were now private pay, or had to qualify for Medicaid if they didn’t have funds to pay or a long term care policy ready to pick up the costs.

A class action law suit filed by the Centers for Medicare and Medicaid Advocacy, and settled in January of 2013, clarified and corrected the Medicare manuals regarding the misconception that a Medicare recipient in a rehabilitation facility must be improving in order to continue to receive the 100 days of Medicare after a qualifying 3 day hospital stay. Even more recently, those denied in the past have a right to have denials reviewed. See below the message from The Center.

Teresa K. Bowman, Esq.

Jimmo Class Members Can Now Have Their Coverage Denials Re-Reviewed

If you are covered by Medicare and you have a long-term or chronic condition, you may be eligible to have Medicare re-review your claims that were denied in prior years.  Please read carefully.

In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. Sebelius provides that Medicare beneficiaries who were previously denied Medicare coverage may have claims re-reviewed under the revised manual provisions.  The process is not automatic: people who wish to take advantage of the re-review process must fill out and submit a form, known as a Request for Re-Review, which is now available on the Center for Medicare Advocacy’s website and the CMS website.  This article explains the process and the form.

Medicare Claims Eligible for Re-review

A Medicare beneficiary may be eligible for re-review if she:

  1. Has received skilled nursing or therapy services in a skilled nursing facility, home health setting, or outpatient therapy setting, and
  2. Has received a partial or full denial of Medicare coverage for those services based on the lack of improvement potential, and
  3. The denial became final and non-appealable on or after January 18, 2011.

Let’s look closely at that last requirement:

It means that the beneficiary had sought Medicare coverage for services provided and received a denial at some level of Medicare’s decision-making process which, because the beneficiary did not seek further review, became final on or after January 18, 2011.  For example, if a beneficiary received a denial prior to January 18, 2011 and could have appealed that decision on or after that date, but chose not to, she would be eligible now for re-review of that claim.  Another way to think of it is: On January 18, 2011, was there still time to seek further review at the next level?  If so, the beneficiary would qualify for re-review of that claim.  On the other hand, if, prior to January 18, 2011, it was too late for the beneficiary to appeal that claim to the next level, the beneficiary would not qualify for re-review of that claim.

Claims Not Eligible for Re-review

Claims that became final and non-appealable after January 23, 2014 are not eligible for re-review.  Consequently, any denied claim that was still “alive” after January 23, 2014 should proceed through the normal Medicare administrative process.  The denial should be appealed to the next level of review, where it will be reviewed under the now-revised manual provisions.

Thus, the claims that are eligible for re-review are denials that were alive on or after January 18, 2011 (even though the services for which the claim was made could have taken place prior to that date) through January 23, 2014.

Deadlines for Filing Request for Re-Review Form

There are two different deadlines for filing the form and obtaining re-review.  If the claim became “final and non-appealable” from January 18, 2011 through January 24, 2013, the deadline for filing is July 23, 2014.  If it became “final and non-appealable” from January 25, 2013 through January 23, 2014, the deadline is January 23, 2015 (six months later than the first group’s deadline).  The best practice, of course, is to file the re-review form as soon as possible so that there is no doubt about timeliness.

The Request for Re-Review Form

The form consists of two parts.  The first part asks six questions about the claim.  These questions represent a worksheet to help beneficiaries decide whether to seek re-review and need not be submitted as part of the Request for Re-review.  There are three possible answers to each question: Yes, No, and Don’t Know.  The purpose of the form is to determine whether the individual meets the requirements for re-review, i.e., whether she has a claim that falls within the time guidelines.  If the answer to any question is No, then the individual is not eligible for re-review.  If the individual answers Yes or Don’t Know (in any combination) to the six questions, then she is eligible to file the Request for Re-review.  That does not necessarily mean that the coverage denial will be reversed, but it is the first step toward that goal.

The second part of the form is a one-page request for information about the Medicare beneficiary and the claim, including a section labeled “Reason(s) for Disagreement with the Final Claim Decision” and the opportunity to submit additional evidence.  Once that part of the form is completed, the Request can either be faxed to a number listed on the form or sent by mail to the listed address.  The Request must be postmarked or faxed no later than the deadline applicable to the group in which the Medicare beneficiary belongs, either July 23, 2014 or January 23, 2015.

Faxing or mailing the completed Request will meet the filing requirement.  It will go to Q2 Administrators, which has been hired by Medicare to process the requests for re-review.  The company will then direct the Request to the level of decision-making where the last decision on the claim was made.  For example, if the beneficiary had received a denial at the reconsideration level, but had not requested further review, the Request for Re-Review would be sent on to the entity handling reconsiderations to make a new decision in light of the revised manual provisions.

If the claim is still denied, the Medicare beneficiary has the right to appeal the re-review decision to the next level of the Medicare appeals process, as she would with any denied claim.


The re-review process is intended to assist Medicare beneficiaries who were denied coverage in the past and who paid out-of-pocket for their skilled nursing or therapy, or who have an outstanding bill for the needed services.  Medicare coverage is not automatic, however.  To see whether Medicare coverage is a possibility, the individual or her advocate must start the process by filling out and submitting the Request for Re-Review.  That action begins with getting the form, which is available here.  Further information on the Jimmo re-review process is available on the Center’s website.

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