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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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hospital appeals

A Medicare beneficiary has the right to appeal a hospital discharge if he or she feels too sick to leave. A Medicare beneficiary can do this even if he or she is in a Medicare Advantage (MA) plan. The hospital will provide "An Important Message from Medicare," which explains how to appeal the discharge. 

Medicare beneficiaries can call KEPRO for an appeal. KEPRO staff members will look at the medical record to see if the beneficiary should stay in the hospital. The beneficiary will be informed of the decision. 

  • The Medicare beneficiary does not have to leave the hospital.
  • The Medicare beneficiary does not have to pay for the extra days in the hospital while KEPRO staff members review the medical record.

other appeals

A Medicare beneficiary has the right to appeal a discharge if he or she does not agree with the decision that skilled services will be stopped. The beneficiary must be given a letter with the planned discharge date explaining how to appeal. A Medicare beneficiary can appeal even if he or she is in an MA plan. 

Once the beneficiary receives the letter, he or she can call KEPRO. A KEPRO physician will look at the medical record to see if the services should continue. The Medicare beneficiary will be informed of the decision.

managed care denial of coverage

If a Medicare beneficiary is in an MA plan, he or she has some additional Medicare rights. If the beneficiary feels he or she cannot get the needed care, he or she has the right to appeal to the MA plan. The Medicare beneficiary can appeal things like denials for:

  • Referrals to a specialist;
  • Approval for tests (like x-rays or blood tests); and
  • Payment of a bill.

The HMO has information about how to start the appeal process. A Medicare beneficiary who feels he or she may get worse by waiting too long can ask for an expedited appeal. This means the HMO must make a decision about the appeal within three calendar days. If you need this faster review, ask your HMO for an “expedited appeal.” 

For additional information about a denial of coverage, call 1-800-MEDICARE.

kepro contact information

KEPRO Region 1 – Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Appeal Helpline - 888-319-8452

KEPRO Region 4 – Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Appeal Helpline - 888-317-0751

KEPRO Region 6 – Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Appeal Helpline - 888-315-0636

KEPRO Region 8 – Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Appeal Helpline - 888-317-0891

KEPRO Region 10 – Alaska, Idaho, Oregon, Washington

Appeal Helpline - 888-305-6759

TTY for all areas: 855-843-4776 

For additional information about asking for medical records, please complete a Medical Record Request Form.

 


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