Medicare Opens Re-Review Process for Some Claims Denied Under Old Improvement Standard

As part of the January 2013 class-action settlement agreement that prevents Medicare from denying coverage to beneficiaries for skilled nursing, physical, occupational, and speech-language therapy services solely for lack of improvement, a “Re-review” process was created to help determine if some prior claims were improperly denied.

What is the Re-Review Process?
The process was officially launched by the Center for Medicare and Medicaid Services (CMS) on January 24, 2014. It allows a Medicare beneficiary to request a CMS review of a therapy services-related claim that was already denied because of the Improvement Standard. Revisions to the Medicare policy manual now make it clear that Medicare coverage may be available for skilled nursing or therapy services to maintain a person’s condition.

Who is Eligible?
A Medicare beneficiary may be eligible for re-review if he or she:

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

How Do I Apply for a Re-Review?
It is solely up to you as the beneficiary to ask CMS for a Re-Review. There is now a form on the CMS website to help get the process started. The form includes a few introductory questions to help you determine whether your claim may be eligible for Re-Review and contact information if you need additional assistance.

The Center for Medicare Advocacy also has great information and resources on how the Re-Review process is designed to work.

There is only a limited window to ask CMS to Re-Review your denied therapy services claim. Here are two key dates to keep in mind.

  • July 23, 2014 – The deadline to submit a Re-Review form if your therapy claim was final by January 24, 2013
  • July 23, 2015 – The deadline to submit a Re-Review form if your therapy claim was final between January 24, 2013 and January 23, 2014.

Learn more about the broader Medicare Improvement Standard settlement and update to the Medicare policy manual.

Date originally posted:  February 7, 2014.