If you face termination of services from a hospital, skilled nursing facility (SNF), home health agency (HHA), hospice or comprehensive outpatient rehabilitation facility (CORF), you may request an expedited, independent determination.
Note: If you are admitted into a hospital, you will be asked to read and sign a form titled An Important Message from Medicare (PDF) — available in English and Spanish. The message describes your rights, including the right to appeal a notice of discharge. If you feel you are being discharged too soon, ask for the hospital discharge notice in writing. This notice will describe the appeals steps below.
The 4 steps of an expedited appeals process are:
- Step 1: You Receive Notice of Termination/Discharge
- Step 2: You Appeal the Decision to the Quality Improvement Organization (QIO)
- Step 3: The QIO Issues a Decision
- Step 4: You Request Reconsideration by the Qualified Independent Contractor (QIC)
Step 1: You Receive Notice of Termination/Discharge
The provider must give you notice at least 2 visits or 2 days before the proposed end of services. You may appeal if you disagree with the termination and — if the services are provided by an HHA or CORF — a doctor certifies that failure to continue the service may place your health at significant risk. Doctor certification is not required for appealing terminations from other facilities.
Step 2: You Appeal the Decision to the Quality Improvement Organization (QIO)
If you want to appeal to the QIO, you must do so by noon of the day prior to termination of services (this can be done by phone or in writing). When you appeal, you can submit a copy of your medical records and a letter of support from your doctor, if you've requested one. The provider must send you a detailed notice explaining why the services are either no longer reasonable and necessary, or no longer covered. The provider must also continue services for 2 days after the first notice or until the service termination date, whichever is later.
The QIO in California is the Health Services Advisory Group (HSAG). Contact HSAG online or by phone at 1-800-841-1602 or 1-800-881-5980 (TDD for the hearing impaired).
Step 3: The QIO Issues a Decision
After receiving your request for an expedited appeal, the QIO, Health Services Advisory Group (HSAG), has 72 hours to issue a decision. The initial notice of the QIO's decision must be given by phone and followed by a written notice, which must include:
- A detailed explanation of the decision
- A statement explaining when you are liable for payment of services
- Information about your appeal rights, including how to request a reconsideration
Step 4: You Request Reconsideration by the Qualified Independent Contractor (QIC)
Your request for a reconsideration must be made to the QIC (in writing or by phone) by noon of the day following the initial QIO decision notification (in writing or by phone). The QIC must issue a decision within 72 hours of receipt of your request (this period may be extended up to 14 days if you need more time to collect medical records). The QIC's decision may be made by phone, followed by a written notice that must include the same information required in the QIO notice (see above). If you wish to pursue the appeal further, your next request should be for an Administrative Law Judge (ALJ) hearing.
The Qualified Independent Contractor (QIC) for California is MAXIMUS Federal Services.