How do I request an appeal be sent for external review for a Medicare Advantage plan? We’ve exhausted internal appeal levels for a medical necessity denial of inpatient hospitalization level of care. The state insurance commission told me they do not handle Medicare advantage plans. The CMS website states the payor is supposed to submit claims to IRO if denials are upheld, but I don’t think this is happening.

The answer depends on whether you are contracted with the plan and how you filed your internal appeals.

1. If you are contracted with the plan and you appealed on behalf of the provider (hospital), you are allowed whatever internal levels of appeal are provided in your contract and that’s all. The appeal never goes to CMS. External appeal is not available unless it is provided in your contract. The state insurance commission is not involved because Medicare and Medicare Advantage plans are under a federal program.
2. If you are contracted with the plan and you appeal on behalf of the patient using the patient’s appeal rights, the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.
3. If you are not contracted with the plan and you appeal on behalf of the provider (hospital), the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.

Answered by Denise Wilson MS, RN, RRT, Senior Vice President Intersect Healthcare + AppealMasters, President, AHDAM