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Appeals We are the Medicare Quality Improvement Organization, working to improve the quality of care for Medicare beneficiaries. Our site offers beneficiary and family-centered care information for providers, patients, and families. Welcome! |
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- Overview
- Beneficiary Complaints
- Other Reviews
- Medical Record Electronic Submission
- Educational Resources
- Physician Acknowledgement Monitoring
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- Memorandum of Agreement
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- Appeals Process Flow Chart (PDF)
contact kepro
Click below to get Kepro's telephone number, fax number and mailing address for your state.
case status
As always, you can check the status of an appeal that has been started online.
hospital discharge appeals
a new process for hospital discharge appeals
As part of Kepro’s Immediate Advocacy services, the Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO), Kepro, will now offer beneficiaries and/or their representatives Immediate Advocacy assistance for discharge planning when filing an appeal.
The goal of this new process is to reduce the number of appeals needed regarding discharge planning.What is different about the hospital discharge appeals process?
Some hospital discharge appeals are filed due to concerns with discharge planning rather than issues with the actual discharge. To address this specific issue, Kepro will work with facilities to ensure that Medicare beneficiaries with Traditional Medicare and/or their representatives clearly understand their discharge plans before continuing with the discharge appeal process.
With beneficiary/representative-initiated discharge appeals, the established appeals process steps will take place to obtain needed information and start the appeals process.
Starting on May 1, 2024, a beneficiary with Traditional Medicare and/or their representative calling Kepro to file a discharge appeal due to concerns with discharge planning will be connected to Immediate Advocacy department. At that time, Kepro will determine what discharge planning has taken place, if there are any gaps or misunderstandings, and whether further discharge planning needs to occur.
With beneficiary/representative approval, Kepro will call the hospital case management team to discuss the discharge planning. Kepro will facilitate a three-way call with the beneficiary or representative and hospital case manager. At that time, missing or unclear items related to the discharge will be discussed. If the hospital case manager prefers to meet with the beneficiary in person, Kepro staff will offer to be present on the phone with the beneficiary/representative during the face-to-face meeting.The beneficiary/representative will be asked a series of questions that include:
- Has the hospital talked to you about your discharge plan?
- Where is your discharge destination or have your location options been discussed?
- Has safe transportation been arranged?
- Do you understand the discharge plan?
- Do you have someone to assist you (if returning home)?
- Do you have the necessary durable medical equipment or has delivery been arranged?
- Do you need home health services (if returning home), such as therapies or nursing care?
- Has the hospital provided information on community services?
By asking these questions, Kepro can help beneficiaries and their representatives understand and finalize their discharge plans. This may result in an appeal no longer being needed.
If the call is successful to solidify the discharge plan, and the beneficiary/representative feels there is no longer a need for an appeal, Kepro will cancel the appeal. The hospital will also be notified.If the call does not resolve the discharge plan, the appeal will continue.
cms final rule
On November 27, 2006, CMS published a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. Beginning July 1, 2007, hospitals must deliver the Important Message from Medicare (IM) to inform all Medicare inpatients, including Medicare Advantage enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible patients about their hospital discharge appeal rights.
Hospitals are required to give a Detailed Notice of Discharge (DND) to patients who choose to appeal a discharge decision. The DND outlines the specific reasons for discharge and applicable Medicare coverage guidelines.
Current versions of the Important Message from Medicare (IM), Form CMS-10065, and the Detailed Notice of Discharge (DND), Form CMS-10066, are posted on the Hospital Discharge Appeal Notices page of the CMS website under Downloads.
hospital requested review (hrr)
HINN 10, also known as the Notice of Hospital Requested Review (HRR), should be issued by hospitals to patients with Original Medicare whenever a hospital requests a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) review of a discharge decision without physician concurrence. To initiate an HRR, the hospital staff should call Kepro, and then electronically send the medical record. HRRs are completed Monday - Friday and will be completed within two business days of the receipt of all pertinent information requested.
expedited determinations
Home health agencies (HHAs), skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and hospices with patients that have Medicare are required to notify them of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.
HHAs, SNFs, hospices, CORFs, and swing beds (under instruction) are required to provide a Notice of Medicare Non-Coverage to Medicare patients (including those patients with a Medicare Advantage plan) to alert them that a Medicare-covered item or service is ending and give patients the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Notice is given when the BFCC-QIO review is requested in order to provide more explanation on why coverage is ending.
