Expedited Medicare Part A Appeal of a Discharge Order From a Facility Other Than a Hospital

If you think your Medicare-covered stay in a skilled nursing facility or your services from a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice agency is ending too soon, you have the right to request an expedited, or "fast," appeal if you disagree with the decision.

The Basics of a Fast Appeal

As a beneficiary who is receiving services under Medicare Part A for care received in a skilled nursing facility (SNF) or from a comprehensive outpatient rehabilitation facility (CORF), a home health agency (HHA), or a hospice agency, you may request an expedited review, also known as a "fast appeal," if the provider decides to terminate your services or discharge you too soon. While there are five total levels of appeal, only the first two levels can be done on an "expedited" basis.

It is important to follow the correct procedure for a fast appeal of a discharge from one of these non-hospital providers, which is different from the procedures for requesting a fast appeal in a hospital setting. (For information, read our article on how to request a fast appeal of your hospital's discharge order.)

How to Request an Expedited Appeal From a Discharge or Termination of Services

You will receive a standard termination of services or discharge notice from your health care provider at least two days (or two visits) in advance of the proposed termination or discharge date. This is also known as a "Notice of Medicare Provider Non-Coverage." This notice will advise when your Medicare coverage will end, when and where to file an appeal, and whether you will be financially responsible if you continue to receive services pending your appeal. If you disagree with the decision, follow the directions in the notice to request an expedited review by the Quality Improvement Organization (QIO) for your area.

If you do not get this notice but are told your services will be terminated or that you will be discharged, ask for it. Read it very carefully, as it contains important information about your appeal rights.

If you are appealing a termination of services provided by a home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF), then you will need to ask a licensed doctor to certify that failure to continue the services may place your health at significant risk. You do not need a doctor certification to appeal the termination of services from a skilled nursing facility or hospice agency.

Level 1 Fast Appeal

Your first level of appeal is to the independent Quality Improvement Organization (QIO) for the area in which you received Medicare services. You will find the name and phone number of the QIO for your area in your notice of termination of services or discharge.

You must request an immediate review from the QIO no later than noon on the day before your scheduled termination of services or discharge. You may make your appeal by telephone or in writing. You may submit documentation in support of your appeal, such as medical records or a letter from your doctor or other health care provider in support of the continued care. After making your request for appeal, the SNF, CORF, HHA, or hospice agency will send you and the QIO a detailed notice explaining why it intends to terminate services or discharge you from the facility.

Note that if you miss the 72 hour deadline, you may still request an expedited review, but different financial responsibility rules and time frames will apply.

QIO's Decision

The QIO has 72 hours from the time it receives your appeal to issue a decision. The QIO will send you a written decision that will include:

• a detailed explanation for the decision
• a statement explaining when you are liable for payment of services, and
• information on how you can appeal the QIO's decision.

If the QIO disagrees with the health care provider's decision to terminate your services or discharge you, in other words it makes a decision in your favor, then you are not financially liable for the cost of the continued services from the skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or hospice agency.

If, however, the QIO agrees with the service provider's decision to terminate services or discharge you, you are financially responsible for any services starting the day after your last day of coverage. This is also the date that is found in the Notice of Medicare Provider Non-Coverage you should have received from your health-care provider at least two days prior to termination of services or discharge.

Level 2 Fast Appeal

If you disagree with the QIO's decision, you have until noon of the day after you receive the QIO's decision to appeal the decision to another independent review group, known as the Qualified Independent Contractor (QIC). This is your second level of a fast appeal, which is also known as a "Request for Reconsideration." Your request may be made in writing or by telephone.

The QIC must normally issue its decision within 72 hours of receiving your written or telephonic request for reconsideration. But you may request that this period be "continued," or extended, for 14 days so that you may collect documentation in support of your appeal, such as medical records or a letter from your doctor or other health care provider showing that continued care is medically reasonable and necessary.

If the QIC is unable to meet the 72 hour deadline to issue its decision, it must notify you of your right to "escalate," or take the case directly to the next level of appeal with an administrative law judge, without waiting for the QIC decision.

QIC's Decision

If the QIC agrees with the health care provider's decision to terminate service or discharge you from its care, you may still pursue three further levels of appeal for Medicare coverage and reimbursement of your costs for this care.

Note that if the QIC agrees with the QIO's decision, your provider can bill you for services starting on the date indicated in the termination notice, or Notice of Medicare Provider Non-Coverage, you received from your health-care provider.

Further Levels of Appeal

If you receive an unfavorable QIC reconsideration decision that says Medicare will NOT cover or pay for your continued stay in a skilled nursing facility or for continued services from a comprehensive outpatient rehabilitation facility, home health agency or hospice agency, you have three remaining levels of appeal:

• a Level 3 hearing with an administrative law judge
• a Level 4 request for review from the Medicare Appeals Council (MAC), and
• filing a lawsuit in United States District Court.

Each of these levels has different timelines and minimum required amounts in dispute. The QIC's decision will contain instructions for a Level 3 appeal, requesting a hearing from an administrative law judge. (For a description of these last three levels of appeal, read our article on regular appeals of Medicare Part A.)

Where to Get Additional Information

For more information on Medicare's expedited appeals process, go to the Medicare website's fast appeals area. If you need help filing your appeal, you can contact:

• your State Health Insurance Assistance Programs (SHIP)
• the Center for Medicare Advocacy, or
• a Medicare lawyer.