A Medicare Advantage organization is requiring certain criteria to be met that is more than what Medicare guidelines require. I don’t understand why they continue to deny after a first level appeal has been done that explains we don’t need to adhere to their requirements that are above and beyond what traditional Medicare requires. Can you help?

Medicare Advantage organizations are not permitted to be more restrictive than traditional Medicare. I suggest you make a complaint to your regional CMS office. Do not include PHI and focus on the facts and violations. Here is a list of regional CMS offices:

Regional Offices and Contact Information

1. Boston ROBO…@cms.hhs.gov
   Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont
2. New York RONY…@cms.hhs.gov
   New Jersey, New York, Puerto Rico, Virgin Islands
3. Philadelphia ROPH…@cms.hhs.gov
   Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia
4. Atlanta ROAT…@cms.hhs.gov
   Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
5. Chicago ROCH…@cms.hhs.gov
   Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin
6. Dallas RODA…@cms.hhs.gov
   Arkansas, Louisiana, New Mexico, Oklahoma, Texas
7. Kansas City ROKC…@cms.hhs.gov
   Iowa, Kansas, Missouri, Nebraska
8. Denver RODE…@cms.hhs.gov
   Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming
9. San Francisco ROSF…@cms.hhs.gov
   Arizona, California, Hawaii, Nevada, Pacific Territories
10. Seattle ROSEA…@cms.hhs.gov
    Alaska, Idaho, Oregon, Washington

Answered by: Karla Hiravi, BSN, RN, AHDAM President and Vice President Clinical Resources, PayerWatch