CurrentHighmark PennsylvaniaPolicy N/A

Detailed Notice of Discharge (Patient QIO Appeal Notice)

A template detailed notice explaining why inpatient hospital services are recommended to end and informing patients about Quality Improvement Organization (QIO) review and Medicare coverage policy references; intended for patients, hospitals, and Medicare-managed care plan members.

Policy Summary

PayerHighmark Pennsylvania

PolicyDetailed Notice of Discharge (Patient QIO Appeal Notice)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf the patient requests, provide copies of documents sent to the QIO by calling 1-800-485-9610 (TTY/TTD 771).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1QIO contact phone provided

0938-1019OMB control number cited

60Estimated time (min)

Coverage Criteria

Medicare coverage policy states that inpatient hospital services that are not medically necessary or that could be safely furnished in another setting are not covered (refer to 42 CFR 411.15(g) and (k)). This notice explains that the hospital, the managed care plan (if applicable), and the treating physician agree the patient’s inpatient services should end on the specified date and directs the patient to the Quality Improvement Organization (QIO) for an independent review of that decision.

If inpatient hospital services are determined to be not medically necessary, Medicare will not cover those services. The notice explicitly informs the patient that Medicare does not cover inpatient services that fail the medical necessity standard or could be provided safely in a lower level of care.

Provider Actions & Requirements

Prior Authorization

Prior Authorization & Documentation Required

Providers must obtain any required prior authorization and ensure timely submission of documentation for inpatient stay reviews. Prior authorization may be required by the plan or applicable Medicare managed care policies; failure to obtain authorization when required can result in claim denial or delayed payment.

Confirm whether the member is enrolled in a Medicare Advantage or other managed care plan and follow that plan's specific prior authorization procedures.

Policy Summary

PayerHighmark Pennsylvania

PolicyDetailed Notice of Discharge (Patient QIO Appeal Notice)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionIf the patient requests, provide copies of documents sent to the QIO by calling 1-800-485-9610 (TTY/TTD 771).

SourceLink

On This Page

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When submitting for QIO review or appeals, include all clinical records that justify continued inpatient care (progress notes, orders, care plans, test results).

Denial Risk

Denial Risk — Medical Necessity

Providers should treat this as an actionable alert: if an inpatient stay is determined not medically necessary or could be provided safely in a lower level of care, Medicare and the plan may deny coverage. Review clinical status against inpatient criteria before admission and throughout the stay to reduce risk of denial.

Evaluate and document medical necessity daily; document why inpatient level of care is required versus observation or skilled nursing.
If transfer or discharge planning is appropriate, document the clinical rationale, discharge destination, and any needed post-acute services.

Documentation Required

Documentation Access — Patient Rights

Patients have the right to request copies of documents sent to the QIO and the specific policies or criteria used in the decision. Providers should inform patients of this right and facilitate requests promptly.

If a patient requests copies of documents or coverage criteria, instruct them to call Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TTD 771).
Maintain a copy of any materials forwarded to the QIO in the patient record and document the patient's request and how it was fulfilled.

Note

Provider Action — Detailed Notice of Discharge

When a Detailed Notice of Discharge is issued, include the specific Medicare and managed care policies that support the discharge decision and the patient’s current clinical information. This ensures transparency and supports any subsequent QIO review or appeal.

Complete the Detailed Notice of Discharge with the discharge date, the coverage policy references relied upon, and a concise summary of the patient’s current medical condition.
Provide patients with the notice and instructions on how to request the QIO review and obtain copies of the supporting documentation.

Discharge Criteria

Hospital inpatient discharge is initiated when the hospital, the patient’s managed care plan (if applicable), and the treating physician agree that inpatient services should end on a specified date because continued inpatient care is no longer medically necessary. The patient is informed of the reason for discharge and given instructions for requesting an independent review by the Quality Improvement Organization (QIO).

Definitions

QIO — definition and role

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

Role in AppealsThe QIO conducts an independent review of the case and issues the decision on the patient’s appeal (the notice is not an official Medicare decision).

Trigger for QIO ReviewA QIO review is requested when the hospital, managed care plan (if applicable), and physician agree inpatient services should end and the patient requests review.

Document Access for ReviewPatients may request copies of the documents sent to the QIO and the specific policies or criteria used to make the decision by calling Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TTD #771).

Relation to Medicare DecisionThis notice explains the hospital’s recommendation; the formal appeal decision will come from the QIO and is separate from this notice.

Background

This detailed notice of discharge explains that the hospital, the managed care plan (if applicable), and the patient’s physician agree inpatient services should end on a stated date. Its purpose is to inform the patient of the rationale for discharge, to notify the patient that this notice is not an official Medicare decision, and to explain how to request an independent review by the Quality Improvement Organization (QIO). The notice also tells patients how to obtain copies of the documents sent to the QIO and the specific policies or criteria used in the decision by calling the Medical Management and Policy Medicare Advantage Appeal Department at 1-800-485-9610 (TTY/TTD #771).