MA Appeal – Untimely Payment

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Dear Director of :

This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse health services as required by Federal law.

Our investigation has concluded the following:

In a recent audit, it has come to our attention that you have failed to satisfy your obligations under 42 CFR § 422.520, which states:

(a) Contract between CMS and the MA organization. (1) The contract between CMS and the MA organization must provide that the MA organization will pay 95 percent of the “clean claims”‘ within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan or are claims for services that are not furnished under a written agreement between the organization and the provider.

(2) The MA organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).

(3) All other claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request.

As you are aware, these services are for emergency services and care.  Pursuant to 42 CFR § 422.113 (b), an MA Organization must cover emergency and urgently needed services—

(2) MA organization financial responsibility. The MA organization is financially responsible for emergency and urgently needed services—

(i) Regardless of whether the services are obtained within or outside the MA organization;

(ii) Regardless of whether there is prior authorization for the services.

(3) Stabilized condition. The physician treating the enrollee must decide when the enrollee may be considered stabilized for transfer or discharge, and that decision is binding on the MA organization.

Section 422.113 (b)(1) defines emergency and urgently needed services as

(b) Emergency and urgently needed services—

(1) Definitions.

(i) Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in—

(A) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;

(B) Serious impairment to bodily functions; or

(C) Serious dysfunction of any bodily organ or part.

(ii) Emergency services means covered inpatient and outpatient services that are—

(A) Furnished by a provider qualified to furnish emergency services; and

(B) Needed to evaluate or stabilize an emergency medical condition.

Under these circumstances, it is your obligation to ensure the continuous provision of quality healthcare to Medicare enrollees, and comply with the prompt payment provisions of Sec. 422.520 in order to indemnify the beneficiary enrollee for payment of any fees that are the legal obligation of the MA organization for services furnished by providers that do not contract, or that have not otherwise entered into an agreement with the MA organization, to provide services to the organization’s beneficiary enrollees.

We hereby demand immediate payment of the above referenced claim(s) plus interest pursuant to sections 1816(c)(2)(B) and 1842(c)(2)(B).  Should you fail to remit payment to the undersigned within ten (10) days, be advised that we may draft a formal complaint to the Centers for Medicare and Medicaid Services (CMS) to ensure our rights under federal and state law are preserved.

Please make any further action on our part unnecessary, by remitting payment in full immediately.




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