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Hospital Discharge Appeal Rights. Patti Johnson, RN, CPHQ Director, Review Services Quality Insights. Hospital Discharge Appeals. Began July 2, 2007. Beneficiaries Affected. Traditional Medicare beneficiaries Medicare Advantage enrollees Dual eligible (Medicare & Medicaid)

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hospital discharge appeal rights

Hospital Discharge Appeal Rights

Patti Johnson, RN, CPHQ

Director, Review Services

Quality Insights

hospital discharge appeals
Hospital Discharge Appeals
  • Began July 2, 2007
beneficiaries affected
Beneficiaries Affected
  • Traditional Medicare beneficiaries
  • Medicare Advantage enrollees
  • Dual eligible (Medicare & Medicaid)
  • Beneficiaries with Medicare as a secondary payer
facilities affected
Facilities Affected
  • Any hospital that provides inpatient care
    • Short Term Acute Care Hospitals
    • Long Term Acute Care Hospitals
    • Critical Access Hospitals
    • Inpatient Psychiatric Hospitals
    • Inpatient Rehabilitation Hospitals
  • If transferring to another acute care inpatient setting, follow-up copy of IM NOT required prior to leaving original hospital
  • Receiving facility delivers initial copy of IM again after transfer into new facility
exclusions to process
Exclusions to Process
  • Swing beds in hospitals – considered lower level of care
  • Beneficiary exhausts Part A days
  • Hospital outpatients who are receiving Part B services
exclusions to process continued
Exclusions to Process (Continued)
  • Admissions for services that Medicare never covers
  • Outpatient departments (ED, Observation)
  • Patients signing out AMA
issuance of important message im
Issuance of Important Message (IM)
  • OMB Approval # 0938-0692 (CMS-R-193)
  • Must issue IM within two calendar days of admission
  • Must obtain signature of patient or representative and provide copy
  • If beneficiary refuses to sign, date of refusal is noted as date of receipt
  • Preadmission – no more than 7 calendar days in advance of admission
issuance of important message im1
Issuance of Important Message (IM)
  • Patient unable to sign and representative unavailable
    • Facility must contact representative by phone, explain IM and note understanding on IM under additional information space (mail or fax notice same day)
    • If unable to contact by phone or no return call, note attempts in additional information space
    • Can send IM by certified mail
    • Voice mail messages alone are not acceptable
    • When sent by delivery, valid delivery date is date letter is signed or date of refusal to sign
delivery of follow up im
Delivery of Follow Up IM
  • Deliver follow up IM no more than two calendar days before discharge
  • May be either a new blank IM or a copy of the IM that was signed after admission
  • Must obtain a date and signature on blank copy or date and initial on signed original IM in space provided
  • When original IM was delivered within two calendar days of discharge, NO follow up copy is required
timing of notice delivery
Timing of Notice Delivery
  • Admitted on Monday
  • Given Initial IM on Wednesday
  • Discharged on Friday (follow up copy of IM not required)
delivery of follow up im1
Delivery of Follow Up IM
  • Routine delivery of the follow-up IM on the day of discharge should be avoided
  • When follow up IM is given on day of discharge, patients should be given at least four hours to consider discharge appeal
  • If patient’s condition changes and he or she is not discharged, another follow up IM should be delivered within two calendar days of new discharge date
detailed notice
Detailed Notice
  • Must be OMB approved notice – Approval Number 0938.1019 (CMS 10066)
  • Must deliver Detailed Notice no later than noon the day after the QIO notifies hospital of the Request for Appeal
  • For MA Plan enrollees, the Plan must directly or by delegation deliver a Detailed Notice
request for expedited review
Request for Expedited Review
  • Request for review made no later than midnight of the day of discharge (Expedited Review)
  • QIO available seven days a week from 8:30 a.m. till 5:00 p.m., off hours – voice mail
  • QIO notifies the hospital and MA Plan of request for review
  • Upon notification by QIO, Detailed Notice is delivered no later than noon of the day after the QIO’s notification
skilled nursing facility placement
Skilled Nursing Facility Placement
  • Discharge planning would include arrangements and verification of available SNF bed
  • If SNF bed becomes unavailable during appeal process, QIO will continue appeal
  • Hospital should pursue another SNF placement as quickly as possible
  • Patient can’t be held liable if SNF bed becomes unavailable
qio process
QIO Process
  • Upon notification by QIO, hospital must supply medical record, copy of IM and copy of Detailed Notice
  • QIO is required to contact the MA Plan
qio process continued
QIO Process (Continued)
  • Information must be supplied no later than noon of the day after QIO notification
  • Medical record and Detailed Notice must be received before review can proceed
  • Facilities will be instructed at the time of initial call with QIO whether to overnight mail or fax documents
qio process continued1
QIO Process (Continued)
  • QIO must determine if hospital delivered a valid IM
    • Use standard IM published by CMS
    • IM signed and dated by beneficiary or representative
    • Meets notice delivery timeframes
  • If invalid:
    • Hospital may need to re-issue IM
    • QIO proceeds with review process
    • QIO educates hospital retrospectively
qio process continued2
QIO Process (Continued)
  • QIO must solicit views from the patient or representative
  • Hospital or MA Plan must provide a copy of documentation that was sent to QIO, if requested by the patient or representative (day after request made)
  • QIO must provide opportunity for hospital and MA Plan to explain why discharge is appropriate
qio process continued3
QIO Process (Continued)
  • QIO must make decision within one calendar day after receiving all necessary information
  • QIO will notify (telephonically) beneficiary or representative, hospital, and MA Plan of decision
  • Telephone notification will be followed up with a letter
qio process continued4
QIO Process (Continued)
  • No patient liability during timely expedited review
  • If QIO agrees with discharge, financial liability for beneficiary begins at noon of the day after telephone notification
  • If QIO disagrees with discharge, patient is not financially responsible
  • Process would begin again when a new follow up IM is provided
qio process continued5
QIO Process (Continued)
  • If beneficiary or representative remains as inpatient and is dissatisfied with QIO decision, a reconsideration may be requested
qio reconsideration process continued
QIO Reconsideration Process (Continued)
  • If initial decision is reaffirmed, the date of liability for the beneficiary remains the same
  • Request for reconsideration must be made by noon of the calendar day following notice of initial telephone determination
  • QIO has three days to process reconsideration and notify all parties
qio reconsideration process continued1
QIO Reconsideration Process (Continued)
  • Beneficiary may request an extension up to 14 days for the reconsideration
  • Provider may not bill until reconsideration determination
  • Untimely reconsideration request follows standard claims appeal process
untimely requests for review
Untimely Requests for Review
  • Untimely request = beneficiary or representative does NOT call QIO by midnight on the day of discharge
  • If beneficiary remains in the hospital, the QIO has two calendar days to complete the review following receipt of all requested information
  • Patient not protected from liability during untimely appeal
untimely requests for review continued
Untimely Requests for Review (Continued)
  • Beneficiary no longer in the hospital –
    • Facility provides detailed notice and all information needed to QIO within 30 days of notification of request
    • QIO has 30 calendar days after receipt of all necessary information to make decision
    • Beneficiary can request a review within 30 calendar days of the date of discharge or at any time for good cause
untimely requests for review continued1
Untimely Requests for Review (Continued)
  • MA Plan Enrollee –
    • Untimely requests from an MA Plan enrollee, enrollee must contact the MA Plan
hospital issued notices of noncoverage hinns
Hospital Issued Notices of Noncoverage (HINNs)
  • Preadmission and Admission HINN – process unchanged
  • For MA Plan enrollees – preadmission and admission reviews are responsibility of MA Plan
  • Other HINNs have been retired
qio concurrence hinn
QIO Concurrence (HINN)
  • Hospital determines inpatient care no longer needed
  • Unable to obtain physician agreement
  • Hospital may request QIO concurrence for either FFS Medicare or MA Plan enrollee = Hospital Requested Review
hospital requested review
Hospital Requested Review
  • Hospital Requested Review Process replaces HINN 10
  • QIO concurrence for discharge
  • Revised model language
  • Valid delivery required
hospital requested review continued
Hospital Requested Review (Continued)
  • Hospitals must consult with the MA Plan prior to issuance
  • Hospitals must notify the beneficiary that QIO concurrence has been requested
  • Follow up copy of signed IM held
  • QIO decision made within two days of receipt of necessary information
  • QIO review should not be used to settle disagreement between facility and MA Plan
hospital requested review continued1
Hospital Requested Review (Continued)
  • Hospital provides information to QIO day after the request is submitted to QIO
  • QIO solicits views of beneficiary
  • QIO notifies parties of decision telephonically and followed by letter
  • Patient becomes liable on noon of day after QIO notification
  • Follows same reconsideration process
qio availability for hinns
QIO Availability for HINNs
  • Accepts hospital requests for preadmission/admission HINNs and hospital-requested review for QIO concurrence during regular working hours
  • Performs these reviews Monday through Friday
  • Only list pre-admission and admission HINNS on the monthly HINN log
hinn 11
HINN # 11
  • The item or service at issue must be a diagnostic or therapeutic service excluded from coverage
  • The beneficiary must require continued hospital inpatient care
  • HINN 11 ONLY used for services when there is a published Medicare coverage policy (national or local) confirming the service is noncovered
hinn 11 continued
HINN 11 (Continued)
  • HINN 11 will not automatically be reviewed by QIO
  • QIO will only review if a complaint is received from a beneficiary or the Intermediary requests QIO review
hinn letter 12
HINN Letter # 12
  • Located at

Click on FFS HINNs

  • To be used until the “official” hospital ABN is approved
  • To be used when the QIO review outcome agrees with discharge and when beneficiary does not request QIO appeal and doesn’t leave by the date of discharge
key points
Key Points
  • It is extremely important to include discharge planning documentation in the medical record
  • Help beneficiary understand the process
contact information for im
Contact Information For IM
  • Quality Insights of Pennsylvania
    • 2601 Market Place Street, Suite 320, Harrisburg, PA 17110
  • Phone number for IM
    • 1.800.322.1914
important web sites
Important Web Sites
    • Under “Beneficiary Notices Initiative (BNI),” click on “Hospital Discharge Appeal Notices”
    • Check site often for updates
  • Questions may be e-mailed to CMS at
  • Quality Insights’ Web site:
process questions
Process Questions
  • Patti Johnson, RN, CPHQ
    • Director, Review Services
    • Phone: 1.877.346.6180, extension 7628
    • E-mail:

This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number 8SOW-PA-REV07.118 App. 8/14/07