Phone script: ask Medicare for a fast appeal when care is ending
What to say when you phone the Medicare quality reviewer to ask for a fast appeal because a hospital stay, nursing facility, rehabilitation or home health care is ending, and what to write down. For Original Medicare and Medicare Advantage.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. For people with Medicare, including a Medicare Advantage plan, who have been told that a hospital stay is ending, or that skilled nursing facility, rehabilitation, home health or hospice care is ending. Call the day you get the notice. This is not a call to your plan, and it is not a letter. The reviewer is the Quality Improvement Organization (QIO), a Medicare contractor that is not your plan or your provider, and the review is free.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the script
Your script
Date and time of this call: [Date and time of this call] Before you call, have the notice in your hand (for a hospital, the Important Message from Medicare; for other care, the Notice of Medicare Non-Coverage), your Medicare or plan card and a pen. Call now. Do not wait for the facility to arrange it.
Know your time limit before you dial. For a hospital stay, ask no later than the day you are discharged. For skilled nursing facility, rehabilitation, home health or hospice care, ask by noon of the calendar day after you receive the Notice of Medicare Non-Coverage. If your notice gives an earlier time, use the earlier one. If the time has passed, call anyway: a late request is still taken (see the last step).
1. Find the number. The notice names the Quality Improvement Organization (QIO) and gives its phone number. Call that number. If you cannot find it, call 1-800-MEDICARE (1-800-633-4227; text telephone (TTY) 1-877-486-2048) and say: "I need the phone number of the Quality Improvement Organization for my state. I want to ask for a fast appeal because my care is ending." Do not use a number from an old page; these numbers change. 2. When someone answers, say: "My name is [Your name]. My Medicare or plan identification number is [Member ID]. I am a patient at [Doctor, hospital or pharmacy]. I am calling to ask for a fast appeal of the decision to end my [The care that is ending]." 3. Say: "The notice is dated [Date on the notice]. I received it on [Date and time you received the notice]. It says my covered care ends on [Date the notice says covered care ends]. I do not agree. Please accept this as a timely request." 4. Ask: "May I have your name and a case or reference number?" Write both down. 5. Ask: "Please confirm the date and time you recorded for my request." Write them down. 6. Ask: "When will you decide?" Write down the answer. For a hospital stay, the reviewer must decide within one calendar day after it has the information it asked for. For nursing facility, rehabilitation or home health care under Original Medicare, the reviewer must decide within 72 hours of your request. 7. Say: "I understand the provider must show that ending my care is right. Please make sure I get the written explanation of why my care is ending, and tell me when I will have it." (The provider must give it by noon of the next day for a hospital stay, and by the close of business that day for other care. For a hospital it is called the Detailed Notice of Discharge; for other care, the Detailed Explanation of Non-Coverage.) 8. If anyone says your care is ending because you are "no longer improving" or "not making progress," say: "Medicare coverage of skilled nursing and skilled therapy does not depend on whether I am expected to improve. It covers skilled care needed to maintain my condition or to prevent or slow decline. This is the Jimmo v. Sebelius settlement. Please note that I said this." 9. Ask: "What protects me from being billed for the extra days while the review runs, and until when?" Write down the answer. A timely request gives billing protection in the rules; ask the reviewer to explain how long it lasts for your care. 10. Write down: the name of the person, the QIO's name, the date and exact time of the call, the case number, the time the reviewer said it would decide, and anything you were told to do next. 11. Tell the nurse or social worker at the facility that you have asked for the fast appeal, and write down who you told and when. 12. Close: "Let me repeat what we agreed." Read your notes back and ask, "Is that right?"
If no one answers: leave a message with your name, your phone number, your identification number, the date and exact time of your call, and the words "This is a time-limited fast appeal request." Then keep calling, and call 1-800-MEDICARE as well. Write down every attempt with its time. Do not stop because the first try failed.
If you have missed the time limit: still call. A late request is accepted and decided as soon as possible, but the 72-hour deadline and the billing protection do not apply. Someone who is still in the hospital can ask for review at any time.
Before you call
Call the Quality Improvement Organization number printed on your notice. If you cannot find it, call 1-800-MEDICARE (1-800-633-4227). Ask for a case or reference number at the start of the call and again at the end. Ask whether you can also send your request in writing, and keep a note of the answer.
What happens next
- Write up the call the same day: the name of the person, the date and exact time, the case number, what you were promised and by when.
- Wait for the written explanation from your provider or plan, and read it. Under Original Medicare, if the reviewer upholds the decision, you can ask for a faster second review by noon of the calendar day after you are told the decision. When you hear the decision, ask the reviewer what the next step is and its deadline.
- For a hospital stay, a timely request means you are not responsible for the stay, other than normal coinsurance and deductible, until noon of the calendar day after you are told the reviewer's decision.
- The rule for Medicare Advantage lists skilled nursing facility, home health and comprehensive outpatient rehabilitation facility services. It does not list hospice. If hospice care is ending under Medicare Advantage, call 1-800-MEDICARE and ask which review applies to you.
- Free Medicare counseling is available from your State Health Insurance Assistance Program (SHIP): 877-839-2675 or shiphelp.org. The call is not connected to any insurance company.
- Check the date and time on your notice, which controls.
The rule behind this
- 42 CFR 405.1206, expedited determination for a hospital discharge
- 42 CFR 405.1202, expedited determination for ending skilled nursing, home health, rehabilitation or hospice services
- 42 CFR 422.624, Medicare Advantage notice of termination of services
- 42 CFR 422.626, Medicare Advantage fast-track appeals
- 42 CFR 409.32(c), restoration potential is not the deciding factor
Sources
Denial reasons this answers
- Denial reason
Care is ending
Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.