Medicare Improvement Standard Update – Re-Review Request Form Now Available

As I have previously written about, the Jimmo Medicare settlement provides for the re-review of certain Medicare claims under maintenance coverage standards for the skilled nursing care (SNF), home health (HH), and outpatient therapy (OPT) benefits, applicable when a patient has no restoration or improvement potential, but that patient requires skilled SNF, HH, or OPT services to maintain, or to prevent or slow further deterioration of, his or her clinical condition.

The process to request a re-review is not automatic. People who wish to take advantage of the re-review process must complete and submit a “Request for Re-Review” form.  There are important timeframes for requesting a re-review.  Further information and the form to request a re-review can be obtained by clicking on:

CMS revised its policy manual on December 6, 2013 to state the following:

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare  statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.

Further background information can be obtained on the Jimmo settlement by clicking on

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