New Mexico's Health Quality Improvement Organization

Hospital Discharge Appeals

As of July 1, 2007, the Centers for Medicare & Medicaid Services (CMS) revised the process with regard to how Medicare beneficiaries can appeal the decision for discharge from an acute inpatient setting. Hospitals must notify Medicare beneficiaries and Medicare Advantage (MA) plan enrollees about their appeal rights and general liability. This will be accomplished by the hospital issuing the revised Important Message (IM) from Medicare within two calendar days of admission and obtaining the signature of the patient or representative to indicate his/her understanding. The hospital will provide a copy to the patient/representative and keep a copy for the facility.

The initial copy of the IM may be delivered at the time of a preadmission visit, but no more than seven calendar days prior to the actual admission. Hospitals will deliver a follow-up IM as far in advance of discharge as possible, but not more than two calendar days before discharge. However, when the discharge date cannot be predicted, the follow up copy may be delivered as late as the day of discharge. The hospital must give the beneficiary/representative at least four hours to consider requesting an appeal, without being pressured to leave.

If the beneficiary or the beneficiary's representative does not agree with the hospital's discharge decision, the beneficiary or the representative may call the New Mexico Medical Review Association (NMMRA), the Quality Improvement Organization (QIO) for New Mexico and request an immediate review. This request must be made by midnight of the day of discharge. If the request is made after the deadline, the request will be accepted, however, the beneficiary is not protected from financial liability.

NMMRA will notify the hospital of the appeal and inform the hospital to issue the Detailed Notice. The Detailed Notice must be issued by noon of the day after NMMRA's notification. NMMRA will also request:
1. A copy of the complete medical record.
2. A copy of the signed IM.
3. A copy of the Detailed Notice.

The hospital must provide this information no later than noon of the day after NMMRA's notificiation. NMMRA will issue a decision within one calendar day once all the required information has been received.

An appeal can be requested at any time, seven days a week, including holidays. Hospitals are required to have staff available for appeals.

Hospital Requested Expedited Appeals

When a hospital determines that a beneficiary no longer needs inpatient care, but is unable to obtain the agreement of the physician, the hospital may request that NMMRA perform a review. Hospitals must notify the beneficiary that the review has been requested. Hospitals will issue the Hospital Requested Review (HRR) notice. This notice informs the beneficiary that he/she will be contacted by NMMRA to request his/her view about the case and the care he/she needs. It also informs the beneficiary that he/she does not need to take any action until after he/she hears back from NMMRA. NMMRA will contact the hospital, the beneficiary/representative and the physician with:

The determination
Payment consequences of the expedited determination
Date of liability (if any)
The beneficiary/representative's rights to request reconsideration
The timeframe for requesting an appeal

NMMRA's determination is binding to the beneficiary, physician and the hospital except when the beneficiary remains in the hospital and requests reconsideration. When the beneficiary makes a timely request, the hospital may not bill the beneficiary until the reconsideration determination is made. The beneficiary's liability will be based on the determination.

Preadmission/Admission Hospital-Issued Notice of Non-Coverage (HINN)

When a hospital or the hospital's utilization review committee has determined that the services for a beneficiary's stay are not reasonable and necessary, and will therefore not be covered, the hospital or the utilization review committee may issue a preadmission/admission HINN. Medicare beneficiaries then have the right to request an expedited review. Just as with the IM from Medicare, the hospital must ensure that:

They deliver the notice in person
The beneficiary/representative comprehends the notice
The beneficiary/representative signs and dates the notice
The hospital annotates on notice the beneficiary's/representative's refusal to sign
The hospital issues the notice and keeps a signed copy for the facility

If the notice is issued at preadmission, the beneficiary can request an immediate review, but no later than three calendar days after receipt of the notice. If the beneficiary is admitted, the beneficiary/representative can make his/her request at any time during the stay. If admitted and an immediate review is not requested, the beneficiary will be liable for customary charges for all services furnished during the stay, except for those services for which he/she is eligible to receive payment under Part B.

If the notice is issued on admission, the beneficiary can request a review immediately or at any time during the stay. If the admission notice was issued at 3:00 p.m. or earlier on the day of admission, the beneficiary could be liable for customary charges for all services furnished after receipt of the notice, except for those services that the beneficiary is eligible to receive payment for under Part B. If the admission notice is customary, charges for all services furnished on the day of receipt of the notice, except for those services for which the beneficiary is eligible to receive payment for under Part B.

For IM and Detailed Notice, please visit:
www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage.

For preadmission/admission HINNs, please visit:
www.cms.hhs.gov/BNI/05_HINNs.asp#TopOfPage

For hospital discharge appeal tools and resources, please visit:
www.nmmra.org/resources/?group=61&t=Hospital+Discharge+Appeal+and+HINNs