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Expert Q&A

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?

March 27, 2025 · Anna McGraw

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

Related

We recently received a delay of service denial for a NICU baby. The baby needed a non emergent procedure. Because of the fragility of the baby, they were combining 2 procedures at once. Two specialty peds surgeons were involved as well as peds cardiac anesthesia – also complicated by needed a block of a few hours in the OR. It took 2 weeks from the time the needed procedure was identified to when the surgery was scheduled/performed. We received a delay in service denial for 7 days prior to the surgery. Is there some industry “evidence based criteria” standard they are basing this on that you are aware of?
Expert Q&A

We recently received a delay of service denial for a NICU baby. The baby needed a non emergent procedure. Because of the fragility of the baby, they were combining 2 procedures at once. Two specialty peds surgeons were involved as well as peds cardiac anesthesia – also complicated by needed a block of a few hours in the OR. It took 2 weeks from the time the needed procedure was identified to when the surgery was scheduled/performed. We received a delay in service denial for 7 days prior to the surgery. Is there some industry “evidence based criteria” standard they are basing this on that you are aware of?

Mar 27, 2025
Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?
Expert Q&A

Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?

Mar 27, 2025