CurrentHighmark Blueshield NenyPolicy N/A

Detailed Notice Of Discharge — Medicare inpatient notice and appeal rights

Explains to patients the notice they receive when a hospital and physician believe inpatient services should end and outlines Medicare review rights and contact information; affects hospitalized Medicare beneficiaries and their managed care plans.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDetailed Notice Of Discharge — Medicare inpatient notice and appeal rights

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf the patient requests review, submit the case to the Quality Improvement Organization (QIO) for independent appeal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 minestimated time to complete information collection

1-800-485-9610appeals phone

0938-1019OMB control #

Medicare Inpatient Coverage Criteria

Medicare inpatient medical necessity

Covered only when services meet Medicare medical necessity and cannot be safely furnished in a lower level of care.

Policy Summary

PayerHighmark Blueshield Neny

PolicyDetailed Notice Of Discharge — Medicare inpatient notice and appeal rights

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf the patient requests review, submit the case to the Quality Improvement Organization (QIO) for independent appeal.

SourceLink

On This Page

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Medicare inpatient coverage requirement: Inpatient hospital services are covered when medically necessary and cannot be safely furnished in another setting

References 42 CFR 411.15 g and k

Medicare does not cover inpatient hospital services that are not medically necessary or that could be safely furnished in another setting. This exclusion references 42 CFR 411.15(g) and (k) and applies when the services provided during an inpatient hospital stay do not meet Medicare medical necessity or could be delivered at a lower level of care.

Services that are determined to be not medically necessary, or that could safely be provided in an alternative setting, are not covered by Medicare. Providers should document the clinical rationale demonstrating why inpatient care is required when asserting medical necessity.

Required Provider Actions and Patient Notice

Note

QIO review and appeal contact

If the patient requests review, the case is reviewed by the Quality Improvement Organization (QIO). The QIO is an independent reviewer engaged by Medicare; the QIO's decision on the appeal is the official determination.

To request QIO review, contact the QIO as instructed on the patient's discharge/appeal notice.
This notice is not an official Medicare decision — the QIO issues the final appeal determination.

Prior Authorization

Action required: provide the patient with the detailed notice of discharge and any appeal instructions. Ensure the case is prepared for QIO review if requested.

Confirm the patient received the detailed notice explaining why inpatient services are ending.
Include managed care plan information when applicable.
If the patient requests review, forward the case and supporting documentation to the QIO per CMS procedures.

Documentation Required

Documentation and disclosure to patient

Document and disclose to the patient the specific information used to make the discharge/coverage decision, including the current medical condition and the Medicare coverage policies or criteria applied.

Provide specific Medicare coverage policy references and any managed care policy citations used in the decision.
If requested, furnish copies of documents sent to the QIO and the specific policies or criteria used to make the decision (contact Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610; TTY/TDD 711).
Record in the medical record the rationale for inpatient discharge vs. alternative settings.

Denial Risk

Medicare coverage denial risk

Medicare does not cover inpatient hospital services that are not medically necessary or that could be safely furnished in a lower level of care. Denials based on lack of medical necessity or availability of alternative settings may be appealed to the QIO.

Denial risk applies when inpatient services are not supported by documentation of medical necessity.
If managed care plan policies were applied, document which policy and how it influenced the decision.

Background

This notice is used when the hospital and treating physician agree that inpatient hospital services should end based on Medicare coverage policies and the patient’s medical condition. It informs the patient of their right to request an independent review by the Quality Improvement Organization (QIO), whose decision will be the official appeal outcome.

Key Definitions

QIO — Quality Improvement Organization (QIO)

DefinitionQuality Improvement Organization (QIO): an independent reviewer hired by Medicare to review the case and render the official appeal decision.

RoleReviews the patient’s appeal and issues the official Medicare appeal decision.

Patient rightPatients may request a QIO review and obtain copies of documents and specific policies used in the decision.

Contact for copiesMedical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TDD #771) to request documents sent to the QIO or policy criteria.

Context of useUsed when the hospital and treating physician agree inpatient services should end based on Medicare coverage policies and the patient’s condition.

Hospital Inpatient Discharge Criteria

Hospital and treating physician agree that inpatient hospital services should end based on Medicare coverage policies and the patient’s medical condition. Coverage is allowed only when services meet Medicare medical necessity and cannot be safely furnished in a lower level of care.