Reviews of Provider Discharges/Service Terminations and Denials of Hospital Admissions
Your Right To a QIO Review
As a Medicare beneficiary, you have the right to a QIO review of healthcare decisions that you disagree with. Please be sure to share this information with your family. Types of reviews you may request:
File a Hospital Discharge Review if you believe you are not medically ready to go home from the hospital, or if you have not received clear discharge instructions.
• Before filing an a review request, consult with your doctor or the discharge planner to see if they will extend your stay.
• If your stay is not extended, ask the hospital for a written notice that explains why you are being discharged and gives the exact date that your Medicare coverage ends. This notice is called an Important Message from Medicare.
• Once you receive the notice, call QSource immediately or by midnight of the day of your planned departure. If you call QSource by this time, you will be able to remain in the hospital while your case is being reviewed. It may take a few days, but you cannot be sent home or billed by the hospital* until the review of your case is completed.
* Except for deductibles and items not normally covered by Medicare.
• Call Qsource if you believe your services should still be covered. You must request a review by noon the day before the notice states your Medicare coverage will end.
• Once your request a review, Qsource asks your Medicare health plan or provider to submit specific information. If all the necessary information has been provided, a decision on the appeal will be made by 5:00 p.m. the next day if you are a Medicare health plan enrollee and within three calendar days of your request if you are an original Medicare beneficiary.
File a Termination of Service Review if you disagree with your healthcare provider’s or Medicare health plan’s decision to terminate coverage from a nursing home, home health agency, hospice, or comprehensive outpatient rehabilitation facility.
You should receive a notice of noncoverage at least two days before your coverage of service ends. You have the right to appeal your healthcare provider’s decision to terminate coverage from a nursing home, home health agency, hospice, or a comprehensive outpatient rehabilitation facility.
• Call Qsource if you believe your services should still be covered. You must request an appeal by noon the day before the notice states your Medicare coverage will end.
• Once you request an appeal, Qsource asks your Medicare health plan or provider to submit specific information. If all the necessary information has been provided, a decision on the appeal will be made by 5:00 p.m. the next day.
You cannot be sent home or billed for services until the review of your case has been completed.
Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
This page is paid for by our Medicare QIO Program Contract.