Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193, to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable. These requirements were published in a final rule,
CMS-4105-F: Notification of Hospital Discharge Appeal Rights
, which became effective on July 1, 2007.
KEPRO will notify the hospital provider of the beneficiary's
request for appeal and will request that medical information be
sent for review. Under federal rules and regulations, the provider
is required to submit the medical information by noon on the day following notification by KEPRO. Since August 2014, KEPRO has utilized a follow-up call or fax transmission as a reminder to providers when requested medical information, associated with appeals, has not been received. Effective December 12, 2016, KEPRO will no longer provide this courtesy reminder.
Hospital Discharge Appeal Process
Hospital discharge appeal requests are made when a beneficiary/representative calls KEPRO after a discharge order has been written by the attending physician stating that the beneficiary no longer requires acute level care. At this point, an IM is given to the beneficiary/representative, and appeal rights are explained. The beneficiary/representative has until midnight on the day the discharge order was written to file a timely request to KEPRO for additional covered time in the hospital or acute setting. A beneficiary may discharge at any point in the appeals process, and KEPRO would still proceed with the appeal review to ensure liability protection. A beneficiary also may appeal the discharge up to 30 days after being discharged from the hospital, to prevent financial liability. In order for the appeal to be processed, the hospital must provide documentation of a safe discharge plan for the beneficiary; if this documentation is not provided, the appeal case is closed.