Patient Appeals
VHQC reviews expedited appeals of provider-issued notices that Medicare will not or will no longer cover healthcare services delivered by hospitals, skilled nursing facilities, home health agencies, hospices, comprehensive outpatient rehabilitation facilities or Medicare Advantage managed care plans.
These reviews must take place within very short timeframes, and some are conducted seven days per week. Providers should be prepared to supply medical records and participate in the review process on weekends. Appeals determinations always are made by a physician reviewer.
Hospital-Issued Notices of Non-Coverage (fee-for-service) and Medicare Advantage Fast-Track Appeals (managed care) are reviewed at the request of the hospital or patient/representative when the hospital plans to discharge the patient because it has determined that Medicare will not cover or will not continue to cover services. VHQC no longer reviews hospital-issued notices on a retrospective basis.
Benefits Improvement & Protection Act Expedited Appeals are reviewed at the request of the patient/representative when the skilled nursing facility, home health agency, hospice, comprehensive outpatient rehabilitation facility or hospital swing bed unit has determined that services will no longer be covered by Medicare and therefore must be terminated. VHQC reviews these appeals for both Medicare fee-for-service and Medicare Advantage enrollees.
For provider assistance with appeals, call the toll-free VHQC provider hotline at 1-800-854-5244. Our experienced nurses are available to help you select the appropriate notice and issue it at the proper time.
Medicare patients/representatives who want to make an expedited appeal should call the toll-free VHQC expedited appeals line at 1-866-263-8402. Our experienced nurses will ask you for the information we need to begin the appeals process.
