HealthInsight New Mexico

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Discharge Appeals

Medicare beneficiaries have certain rights that can help prevent a premature discharge from a hospital, skilled nursing facility (SNF), home health agency (HHA), comprehensive outpatient rehabilitation facility (CORF) or hospice. If a facility or health plan prepares to discharge a beneficiary, but the beneficiary does not feel ready to leave, the discharge decision can be appealed. NMMRA is the organization in New Mexico designated by Medicare to review the case if an appeal is made.

How to Initiate a Discharge Appeal

As of July 1, 2007, the Centers for Medicare & Medicaid (CMS) has revised the process with regard to how a Medicare beneficiary who is a hospital inpatient requests an expedited appeal. Hospitals must notify Medicare beneficiaries about their hospital discharge appeal rights. Hospitals must issue, to the beneficiary, the Important Message from Medicare (IM) within two calendar days of admission, must obtain the beneficiary's signature (or the signature of the beneficiary's representative) confirming receipt of the IM, and provide a copy of the IM to the beneficiary at that time. Hospitals will also deliver a copy of the signed notice as far in advance of the discharge as possible, but no more than two calendar days before discharge. If the beneficiary or the beneficiary's representative do not agree with the hospital's discharge decision, the beneficiary or the representative may call NMMRA and request an immediate review. This request must be made by midnight of the day of discharge after the beneficiary has been given the IM. An appeal can be requested at any time, seven days a week, including holidays. After 4:30 p.m., beneficiary/representative requests can be left via voicemail on the appeals request line. These requests will be processed as an expedited appeal the following day as long as the request is made before midnight and it was before or the day of the pending discharge. If the beneficiary/ representative miss the midnight deadline, an expedited appeal will still be performed; however, the beneficiary is not protected from financial liability.

The Your Right to Appeal a Hospital Discharge Flyer provides information about a beneficiary's or his/her legal representative's right to appeal a hospital discharge decision.

If a beneficiary is in a SNF, HHA, CORF or hospice, and he/she or his/her legal representative receives a notice from the provider informing the beneficiary of the decision to terminate services, and the beneficiary or representative disagrees with this decision, the beneficiary or representative can call NMMRA and request an immediate review. This request must be made by noon of the day before the intended discharge date after the beneficiary receives a written discharge notice. If the beneficiary is enrolled in a Medicare Advantage Plan and he/she or the representative misses the noon deadline to appeal, the beneficiary or representative can appeal the decision with the Medicare Advantage organization. The beneficiary enrolled in fee-for-service Medicare or the representative can also contact NMMRA if he/she misses the noon deadline. NMMRA will accept the appeal; however, the appeal will not be expedited. An appeal can be made from 8:30 a.m. to 4:30 p.m. seven days a week, including holidays, with the capability to record calls received outside business hours at any time.

The Your Right Flyer provides information about a beneficiary's or his/her legal representative's right to appeal a discharge decision.

You may contact NMMRA at 505-998-9898 (in Albuquerque) or at 1-800-663-6351.

star image If you are not a New Mexico resident or provider, please contact your state's Quality Improvement Organization.