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Medicare Appeals

Medicare Appeals

Pre-service Appeals (services have not been rendered) for contracted and non-contracted providers

Payment appeals for non-contracted providers

  • Non-contracted providers can appeal decisions regarding payment when a valid Waiver of Liability is completed and submitted to the Plan. This appeal process applies to all of our medical benefits plans.
  • If you received zero payment on a claim, please visit Medicare Member Medical Appeal Process.

Contracted provider requests and non-contracted provider disputes

If you have a dispute around the rate used for payment you have received, please visit Health Care Professional Dispute and Appeal Process.

Discharge appeals for home health, skilled nursing facility, or rehabilitation facility care

All Medicare patients, their legal representative or physician may appeal the discontinuation of services being rendered by a home health agency, skilled nursing facility, or rehabilitation care facility.

The Quality Improvement Organization (QIO) is the first level of appeal for these requests. The QIO must be contacted by noon the following day of the Notice of Medicare Non Coverage (NOMNC) being issued. The applicable QIO reviews the decision to discontinue services. The applicable QIO can be located at http://qioprogram.org/contact-zones.

  • The QIO will contact the hospital staff and the Plan to get medical records for review.
  • The hospital may be asked to share clinical information with a member of Innovation Health’s Medicare Advantage Fast Track Team to complete the CMS-required Detailed Notice of Discharge.

If a Medicare member asks for the review after the required timeframe, the Medicare expedited appeal process will apply. Refer to Medicare Member Medical Appeal Process for how to file an expedited appeal.

Inpatient hospital discharge appeals for contracted facilities  

Please visit Health Care Professional Dispute and Appeal Process.

Inpatient hospital discharge appeals for non-contracted facilities

If a Medicare member asks for the review after midnight on the day of discharge or after leaving the hospital, please visit Medicare Member Medical Appeal Process.

Hospital discharge appeal notices (CMS website)

The Partnership

Together, Aetna and Inova are taking a new approach to the way health care is offered. With this innovative partnership, these two industry leaders aim to provide more efficient and effective patient care at a more affordable cost. By joining the right medical professionals with the right technology, patients receive the benefit of quality, personalized health care. 

Legal Notices & Privacy Policies

Health benefits and health insurance plans are offered and/or underwritten by Innovation Health Insurance Company and Innovation Health Plan, Inc. Innovation Health Insurance Company and Innovation Health Plan, Inc. are affiliates of Inova and of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Innovation Health.

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