What does AFIRM mean in UNCLASSIFIED

AFIRM stands for Appeal Fairness Integrity and Reforms in Medicare, which is a program created by the Centers for Medicare and Medicaid Services (CMS) to ensure that all appeals of coverage decisions made by Medicare are processed fairly and efficiently.

Under the AFIRM program, CMS has extended priority review status to certain types of appeals such as those involving critical care services or end-stage renal disease treatments. This ensures that these appeals are reviewed promptly upon submission. Additionally, CMS requires all Medicare Administrative Contractors (MACs) to assign an additional Quality Assurance representative when handling high-volume appeals cases so that decisions can be made more efficiently.

The Centers for Medicare & Medicaid Services (CMS) is responsible for administering the AFIRM program. CMS works with MACs to ensure that all appeals are addressed properly and resolves any discrepancies between contract administrators in a timely manner.

Yes. Under AFIRM, priority review status is extended to certain types of appeals on a case-by-case basis, such as those involving critical care services or end-stage renal disease treatments, allowing these cases to be handled more promptly than other appeal cases. Additionally, MACs must assign additional Quality Assurance representatives when handling high-volume appeal cases so that decisions can be made more efficiently.

If an appeal is denied after being processed under AFIRM guidelines, there may still be recourse available through external review or independent dispute resolution processes. These processes provide additional opportunities for resolution should the initial decision prove unsatisfactory.