Medicare beneficiaries and Medicare Advantage (MA) plan enrollees who are hospital inpatients have a statutory right to appeal to a Medicare Quality Improvement Organization (QIO) for an expedited review of a discharge decision. 

Hospitals must issue an Important Message from Medicare notice within two calendar days of admission and obtain the signature of the patient or representative to indicate understanding.  A copy should be provided to the patient/representative and a copy of the IMM should be kept by the facility. The initial copy of the IM may be delivered at the time of a preadmission or registration visit, but not more than 7 calendar days prior to the actual admission.

Hospitals will also deliver a follow-up IMM as far in advance of discharge as possible, but not more than two calendar days before discharge. If the initial IM was received and signed as part of preadmission registration, and this occurred more than two calendar days prior to discharge, a follow up copy of the notice is required.

A patient or representative who chooses to exercise the right to an expedited review must submit a request to CIMRO of Nebraska no later than midnight of the day of the planned discharge, and may be in writing or by telephone.

When the patient or representative makes a timely request for a QIO review—that is, requests a review no later than midnight on the day of the planned discharge—the patient is not financially responsible for inpatient hospital services (except applicable coinsurance and deductibles) furnished before noon of the calendar day after the date the beneficiary receives notification of the expedited determination from CIMRO of Nebraska.  Liability for further inpatient hospital services depends on CIMRO of Nebraska’s decision.

As part of the appeal process, the CIMRO of Nebraska Beneficiary Protection/Case Review team is also required to perform a medical necessity/admission screening for hospitals that are reimbursed under a prospective payment system (PPS), as well as performing a quality of care review if a potential quality of care concern is identified during the review of the medical record.  For additional information regarding criteria used to perform the medical necessity/admission screening, visit http://www.cimronebraska.org/utilrev.aspx .