Your appeal rights if you lost your hospital discharge review (Original Medicare)
If you asked a Quality Improvement Organization (QIO) to review the hospital's decision to discharge you, and the QIO decided against you, you can appeal.
If you are still in the hospital
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If the QIO decides against you and you are still in the hospital, you can ask another organization, the Qualified Independent Contractor (QIC) for an immediate (expedited) reconsideration. To get one, you must call or write the QIC by noon the day after you received the QIO's decision.
The QIC must immediately notify the hospital and QIO of the reconsideration request and allow you and the hospital to submit information. The QIC must notify you in writing of its decision within 72 hours of receipt of request for an expedited determination and all necessary information to decide the case. (You can request that this deadline be extended by up to 14 days if you need time to gather additional evidence, for example, if you need to get in touch with your doctor and he or she is out of town). The hospital cannot charge you for care until the QIC reaches its decision.
If the QIC misses the 72-hour deadline for decision, you have not requested an extension, and at least $140 is at stake (in 2013), you can ask that the appeal be automatically transferred to the Administrative Law Judge (ALJ), the next level of appeal.
If you missed the deadline for a reconsideration or have left the hospital
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If you missed the deadline for the expedited reconsideration or you have left the hospital, you can request a standard reconsideration by the QIC within 180 days of receipt of the QIO's decision. The QIC generally has 60 days from your request for a reconsideration to notify you in writing of its decision or of your right to automatically transfer your case to the Administrative Law Judge (ALJ) if at least $140 is at stake (in 2013).
The hospital can bill you before the QIC makes its decision, but must reimburse you any amounts you paid if the QIC later rules in your favor.
If the QIC decides against you, you can appeal its decision to the Administrative Law Judge.
For deadlines and rules of appealing at the ALJ level and beyond, click on "Timeline for Medicare Appeals" in the GO TO box.