Fast appeals when a hospital or facility is ending your care

If a hospital tells you it is time to go home, or a nursing facility, home health agency, rehabilitation facility or hospice tells you Medicare will stop paying, you can ask an independent reviewer to look at that decision quickly. The window is short, and some of it is counted in hours. If this is happening now, start with step 1 and call today.

The independent Medicare reviewer, called the Quality Improvement Organization or QIO, is the office named on your notice. Its phone number is on the notice too. A phone script for the call is ready for you to fill in.

A worked example. Your notice is dated 3 November and says coverage ends on 5 November. If you received it on 3 November, the call to the reviewer is due by noon on 4 November: noon of the calendar day after you received the notice. If your notice names an earlier time, use that. Use the deadline calculator to work out your own date.

If you lost the notice, do not wait. Call 1-800-MEDICARE (1-800-633-4227) and ask for the reviewer for your state. A lost notice is not a reason to let the time pass.

What this means

When you have Medicare, the hospital or provider must give you a written notice before coverage ends. The notice tells you that you may ask for a fast review, and it names the reviewer. In a hospital the notice is the Important Message from Medicare (Form CMS-10065). The hospital must give it to you within 2 calendar days of admission and give you a follow-up copy before discharge. The reviewer is not the hospital and not your plan. It is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), a Medicare contractor that handles these reviews free of charge.

Two organizations hold the current contracts, Acentra Health (formerly Kepro) and Commence Health (formerly Livanta). Which one serves you depends on your state. Older guides use the old names.

What to do

1. Find the notice and the reviewer’s number today (you). The notice you were given has the phone number. If you cannot find it, use the state map published by the Centers for Medicare & Medicaid Services (CMS), or the websites of the two organizations, all linked at the end of this page. You can also call 1-800-MEDICARE (1-800-633-4227, text telephone 1-877-486-2048) and ask for help finding the reviewer for your state.
2. Call before the deadline, not at it (you). You can ask by phone or in writing. If the call is not answered, leave a message and write down the time. The phone script for a fast Medicare appeal gives you the words to say and what to write down.
3. If you are in a hospital (you). Ask no later than the day you are discharged. The hospital must then give you a Detailed Notice of Discharge (Form CMS-10066) by noon of the next day. The reviewer is to decide within one calendar day after it has the information it asked for. The hospital has the burden of proving that discharge is right.
4. If a nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice is ending care (you). The provider must give you a Notice of Medicare Non-Coverage (Form CMS-10123) at least 2 days before covered services end. Ask the reviewer by noon of the calendar day after you receive the notice. When the notice arrives 2 days before the end date, that is usually noon the day before the end date printed on it. If your notice and this rule give different times, use the earlier one. The provider must give you a Detailed Explanation of Non-Coverage (Form CMS-10124) by close of business that day. The reviewer decides within 72 hours of the request, and the provider has the burden of proof.
5. For services such as home health, ask your doctor (your doctor). For non-residential services, a physician must certify that ending the service may put your health at significant risk.
6. Say what your condition needs (you and your care team). Tell the reviewer what happens if care stops. Coverage of skilled nursing and therapy does not depend on whether you are expected to improve. Care to maintain your condition or slow decline can be covered.
7. If the reviewer sides with the provider, ask for the next review at once (you). You can ask the Qualified Independent Contractor for a fast reconsideration by noon of the calendar day after you are told the reviewer’s decision. It must decide within 72 hours of receiving your request and the records.

Check the date and time on your notice, which controls.

What a timely request protects

• Hospital. If you ask in time, you are not responsible for the inpatient stay, other than normal coinsurance and deductible, until noon of the calendar day after you are told the reviewer’s decision.
• Care ending. If the provider’s notice was not valid, the provider is financially liable for continued services until 2 days after a valid notice. A cut in services, as opposed to a complete end, is not a “termination” for this purpose.

If you miss the deadline

You are not out of luck. A late request is still reviewed, but without the fast deadline and without the protection from charges.

• Hospital, still in the hospital. You can ask for review at any time, and the reviewer decides within 2 calendar days.
• Hospital, already discharged. You can ask within 30 calendar days of discharge, and the reviewer decides within 30 calendar days.
• Care ending. The reviewer decides as soon as possible.

If you have a Medicare Advantage plan

The same hospital notice and the same reviewer apply. With a timely request, the plan stays financially responsible until noon of the day after the reviewer’s decision, and the plan has the burden of proof. The Medicare Advantage rule lists skilled nursing, home health and comprehensive outpatient rehabilitation services, and it does not list hospice. The provider must give the non-coverage notice at least two days before services end, and you must ask by noon of the day after you receive it.

The rule

To use the fast hospital discharge review, ask the Quality Improvement Organization no later than the day of discharge, by phone or in writing. (Title 42 of the Code of Federal Regulations (CFR), section 405.1206(b))

Watch for

• Old numbers and names. Do not call numbers from guides that name Livanta or Kepro.
• Midnight versus noon. Some summaries give the hospital deadline as midnight on the day of discharge. The rule says only “no later than the day of discharge”, so call as early that day as you can. For care that is ending, the rule’s time is noon.
• Observation status. A change from inpatient to observation has its own rule. See Medicare observation status.

What next

• Original Medicare: the five appeal levels covers the ordinary appeal that follows if you want to dispute a bill.
• Medicare Advantage appeals covers your plan’s own appeal.
• Free Medicare counseling helps you through the call.
• Get a fast decision when health is at risk covers urgent appeals for other plan types.