Notification of Hospital Discharge Appeal Rights
- Participating Physician Groups (PPG)
Hospitals must deliver a standardized written notice to members of their rights as a hospital inpatient, including discharge appeal rights. Hospital providers are to provide the notice at or near admission, but no later than two calendar days following the member's admission to the hospital. Hospitals must issue an Important Message from Medicare about Your Rights (IM) Form to notify all patients of their rights. If a patient disagrees with the proposed discharge, they can ask the Quality Improvement Organization (QIO) to make an expedited determination of the need for a longer hospital stay. Soon after the patient, or the patient's authorized representative, makes this request, the hospital provider, delegated participating physician group (PPG) or Health Net must issue a Detailed Notice of Discharge (DND) to the patient as well as provide all requested medical records at the QIO's request as soon as possible, but no later than 12:00 p.m. the day following notification of the appeal by the QIO. If the hospital does not issue the DND, Health Net and its delegated participating providers must work together to issue the DND letter to the patient being discharged from the acute facility.
The QIO, which operates 365 days a year, notifies Health Net upon making its determination. A representative from Health Net contacts the hospital and PPG case manager to inform them of the QIO's appeal issue determination, including on weekends and holidays.
If the QIO reverses the discharge determination decision to terminate covered services, the hospital provides the member or authorized representative with a new IM notice when the treating physician determines that the member no longer requires acute inpatient hospital care.
The Centers for Medicare and Medicaid (CMS)-approved DND template can be downloaded from the Health Net provider portal at provider.healthnet.com > Regulatory > Medicare Information > CMS-Approved Model Templates. MA providers may also download the Centers for Medicare and Medicaid Services (CMS)-approved Health Net MA templates from the ICE website at www.iceforhealth.org.