Benefits Improvement and Protection Act (BIPA) Reviews

The Centers for Medicare & Medicaid Services (CMS) has finalized the BIPA review process. This is what we know about this new appeal process:

• CMS has finalized the notices for BIPA reviews. You can access the notices by visiting CMS’s web site. If you are unclear on any aspect of the BIPA review process, please read Expedited Determination Questions and Answers (PDF), provided by CMS.
• These appeals will be similar to the review process implemented January 2005 for Medicare Advantage Plan enrollees.
• The provider will need to provide a written notice to the Medicare beneficiary that services involving a Skilled Nursing Facility, Home Health Agency, Comprehensive Outpatient Rehabilitation Facility, and Hospice will be discontinued.
• This written notice will need to be provided to beneficiaries no later than 2 days before the proposed ending of covered services.
• If the beneficiary requests an appeal from Quality Insights, the provider will need to issue a detailed notice to the beneficiary containing the reasons why services are no longer covered.
• Providers will need to provide Quality Insights with a copy of the beneficiary’s medical record, the initial notice and the detailed notice.

Learn More About BIPA

Recordings of BIPA training sessions and BIPA training materials are available on a separate page.

Also note the resource, What Will a BIPA Review Mean?