Funded by the Centers for Medicare & Medicaid Services, Primaris reviews appeals for Medicare patients who have been notified of their impending discharge from a hospital.
A beneficiary has a right to an expedited determination by Primaris when he/she disagrees with the provider and/or physicians that services should be terminated. A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination to Primaris by midnight of the day of discharge. The beneficiary may submit evidence to be considered by Primaris in making their decision. Medicare coverage of services continues through the appeal process.
Citation and Procedure
The Centers for Medicare & Medicaid (CMS) have always required hospitals to advise Medicare beneficiaries of their right to appeal their hospital discharge. New regulations require hospitals to repeat that message, depending on the patient’s length of stay.
Under the current process, hospitals must provide the Medicare beneficiary or his/her representative with:
- An Important Message from Medicare (IM) notice within two calendar days of admission. The IM has been revised and now informs Medicare beneficiaries of their rights, including discharge appeal rights. The beneficiary or his/her representative must sign and date the notice indicating that he/she has received it and understands its content. Hospitals must retain a copy of the signed IM. Paper files or scanned electronic files are permissible.
- A copy of the signed IM as far in advance of discharge as possible, but no more than two calendar days before discharge. When the hospital can anticipate a discharge, it should provide the IM copy one to two days before discharge. When the hospital cannot anticipate a discharge, it should deliver the IM copy as soon as the discharge can be anticipated. The follow-up IM is not required if the first notice was given within two calendar days of discharge.
When discharge cannot be anticipated, the IM should be given immediately and the patient allowed a minimum of four hours to decide whether or not to request an appeal. The purpose is to ensure that beneficiaries are aware of their discharge appeal rights when it is most relevant – before discharge.
If the beneficiary or his/her representative appeal the discharge decision to Primaris, the hospital must then deliver a detailed notice to the beneficiary or his/her representative that explains:
- Why services are no longer necessary
- Why services are no longer covered according to applicable Medicare coverage rules
- Specific facts to support applicability of the coverage rules
- Other information as required by CMS
- The date the coverage of services ends
If Primaris agrees with the beneficiary that acute care should continue, Primaris will recommend that care continue. If Primaris agrees with the hospitals that services should end, the beneficiary will become liable for costs of continued care beginning at noon the day following Primaris’ notification.
The hospital will give the beneficiary a third notice indicating the date the patient becomes liable for costs of continued care if the patient doesn’t go home. Instructions on how to complete and deliver the IM are available at http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp.
If you have questions regarding this information, please call the Clinical Review Department at 1-866-902-1813.