Appealing a Part A Denial
A beneficiary’s right to appeal a denial of Medicare hospital coverage varies upon whether the attending physician has agreed that in-patient hospital care is no longer necessary. If the attending physician has not agreed, the hospital must obtain the approval of the QIO before it may issue a denial notice to the beneficiary and begin to charge for services rendered. A determination by a QIO that in-patient hospital services are no longer necessary is an Initial Denial Determination subject to appeal. In such cases the beneficiary may immediately request a Reconsideration of the denial by the QIO. The Reconsideration Request must be filed within 60 days after receipt of the Notice of Denial.
Normally reconsideration determinations are issued by the QIO within 30 days after the receipt of the reconsideration. However, in situations where the QIO has denied admission based on pre-admission review, or where the beneficiary is still an in-patient, reconsideration may be sought and determined on an expedited basis. The beneficiary must submit a Request for Reconsideration within 3 days of receipt of the denial notice. The QIO must then issue its reconsideration determination within three working days after receiving the request if the beneficiary is still awaiting hospital admission, or is currently a hospital in-patient for the stay in question.
In cases where the attending physician agrees that the hospital discharge is appropriate, however, the hospital will not normally obtain QIO agreement before issuing a denial notice to the patient and assessing charges for services rendered. In such cases the beneficiary has the right to request an expedited review by the QIO. The following apply if the beneficiary requests QIO review before noon of the first working day after a written denial notice is properly delivered:
The hospital must provide written records to the QIO by the close of that first working day and;
The QIO must issue a review decision within one full working day after the date the QIO received the Review Request and records.
If the patient requests a speedy QIO review as described above, the hospital may not charge the patient for any charges incurred before noon of the day following the day on which the QIO review determination is received by the patient. If the patient is dissatisfied with the result of the QIO review, he or she may still request a reconsideration of that decision. The rules pertaining to reconsideration described above would pertain.
If the patient is dissatisfied with the result of the QIO reconsideration, and the amount in controversy is at least $120, he or she may obtain a hearing by an administrative law judge of the Social Security Office of Hearings and Appeals. This administrative hearing must be requested within 60 days after receipt of the reconsideration decision.