CurrentHighmark Blueshield NenyPolicy N/A

Detailed Notice of Discharge - Coverage Criteria

Explains to a patient why their inpatient hospital services are being ended and provides information about requesting an independent review by the Quality Improvement Organization (QIO). Applies to Medicare beneficiaries and those in Medicare managed care plans affected by a discharge decision.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDetailed Notice of Discharge - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf requested, provide copies of the documents and specific policies used in the discharge decision by calling Medical Management and Policy Medicare Advantage Appeal Department.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1QIO review contact phone number provided

0938-1019OMB control number

60Estimated time (min)

Coverage Determination & Reason for Discharge

Reason for discharge

Basis for discharge determination as stated in the notice

Discharge determination basis: Inpatient services should end because they are not medically necessary or could be safely furnished in another setting as per Medicare coverage policies (42 CFR 411.15(g) and (k)).

This is the stated coverage rationale in the notice.

Insert managed care policy references here when applicable. The notice should state that, for members of a Medicare managed care plan, Medicare Managed Care policies that apply to the member’s plan will be included in the decision documentation and that specific managed care policy citations or plan rules will be inserted into the notice when relevant.

Medicare does not cover inpatient hospital services that are not medically necessary or that could be safely furnished in another setting. (Refer to 42 CFR 411.15(g) and (k).)

Actions for Provider / Patient Rights & Documentation

Policy Summary

PayerHighmark Blueshield Neny

PolicyDetailed Notice of Discharge - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf requested, provide copies of the documents and specific policies used in the discharge decision by calling Medical Management and Policy Medicare Advantage Appeal Department.

SourceLink

On This Page

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Note

Managed care policy notice

Medicare Managed Care policies may apply to this case. If the patient is enrolled in a Medicare Advantage or other Medicare managed care plan, include and follow the specific managed care policies that govern discharge, coverage, and appeals for that plan. Insert the applicable managed care policy identifiers, plan rules, or links when known and notify the member and attending provider of any plan-specific prior authorization, concurrent review, or utilization management requirements that affected the decision.

Note

Detailed Notice of Discharge / QIO review

You have requested a Quality Improvement Organization (QIO) review. This detailed notice explains why the hospital, your managed care plan (if any), and your physician believe your inpatient hospital services should end. This is not an official Medicare determination; the QIO appeal decision is the official determination.

Medicare does not cover inpatient hospital services that are not medically necessary or that can be safely provided in another setting (see 42 CFR 411.15(g) and (k)).
If applicable, the specific Medicare managed care policy(ies) used in this determination should be listed here.
If you want copies of the documents sent to the QIO or the specific policies/criteria used to make this decision, call Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TDD 711).

Documentation Required

Document request for QIO review

If you would like a copy of the documents sent to the QIO or copies of the specific policies or criteria used to make this decision, contact Medical Management and Policy — Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TDD 711). Provide the member name, Medicare number, hospital, and dates of service to expedite the request.

Denial Risk

Medicare coverage risk

Medicare does not cover inpatient services that are not medically necessary or that could be safely furnished in another setting. This determination is made in accordance with Medicare coverage policies and regulations; the final determination on coverage for appeals is made by the QIO.

Inpatient Hospital / Discharge Criteria

Top-level criterion for inpatient hospital services: inpatient services should end when they are no longer medically necessary or can be safely furnished in another setting, based on Medicare coverage policies (see 42 CFR 411.15(g) and (k)). This notice communicates that determination and the rationale for ending inpatient care.

Background & Purpose of Notice

This notice explains the clinical determination that inpatient services should end in accordance with Medicare coverage rules and the patient’s current medical condition. It also informs the patient of their right to request an independent review by a Quality Improvement Organization (QIO) and how to obtain copies of the documents and policies used in the decision.

Key Definitions

QIO — Quality Improvement Organization definition and role as independent reviewer

DefinitionQuality Improvement Organization (QIO): an independent reviewer hired by Medicare to review discharge decisions.

RolePer the notice, the QIO provides the independent review and will issue the official decision on the discharge appeal.

Requesting documentsIf requested, providers or patients may obtain copies of the documents sent to the QIO and the specific policies or criteria used in the decision by contacting the Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TDD #771).

ScopeQIO reviews apply to Medicare beneficiaries and cases involving Medicare managed care plans when a discharge determination is contested.

Authority referencedThe notice references Medicare coverage policies, including 42 CFR 411.15(g) and (k), as the basis for discharge determinations that the QIO will review.