A hospital or Medicare health plan must deliver a completed copy of this notice to beneficiaries/enrollees upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed a discharge from an inpatient hospital stay. A Detailed Notice of Discharge (DND) is given only if a beneficiary requests an appeal. The DND explains the specific reasons for the discharge. The DND must be provided no later than noon of the day after the QIO’s notification.
For purposes of §§405.1204, 405.1205, 405.1206, and 405.1208, the term “hospital” is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals.
For those beneficiaries who request a QIO review, hospitals must deliver a Detailed Notice of Discharge as soon as possible, but no later than noon of the day after the QIO’s notification. If a beneficiary requests more detailed information prior to requesting a review, hospitals may deliver the detailed notice in advance of the beneficiary requesting a review.
A minimum of two copies of the Detailed Notice, including the original, will be needed. The beneficiary keeps the original notice. The hospital must retain a copy of the signed document and may do so electronically.
The Detailed Notice must NOT exceed one side of a page in length. The Detailed Notice is designed as a letter-sized form. If necessary, it may be expanded to a legal-sized page to accommodate information hospitals may insert in the notice. Hospitals may attach applicable Medicare policies to the notice.
The IM and the Detailed Notice must meet the following font requirements in order to facilitate beneficiary understanding:
• Font Type: To the greatest extent practicable, the fonts as they appear in the notices on the CMS Web site should be used. Any changes in the font type should be based solely on software and/or hardware limitations of the notices. Examples of easily readable alternative fonts include: Arial, Arial Narrow, Times New Roman, and Courier.
• Font Effect/Style: Any changes to the font, such as italics, embossing, bold, etc., should not be used since they can make the notices more difficult to read.
• Font Size: The font size generally should be 12 point. Titles should be 18 point, but handwritten insertions in blanks of the IM can be as small as 10 point if needed.
• Insertions in Blanks: Information inserted by hospitals in the blank spaces on the IM and the Detailed Notice may be typed or legibly hand-written using the guidelines above.
Provide the Detailed Notice of Discharge: When a QIO notifies the hospital that a beneficiary has requested an expedited review, the hospital must deliver a Detailed Notice of Discharge (the Detailed Notice) to the beneficiary as soon as possible but not later than noon of the day after the QIO’s notification. If a beneficiary requests more detailed information prior to requesting a review, hospitals may deliver the detailed notice in advance of the beneficiary requesting a review.
The Detailed Notice must be the standardized notice provided by CMS and contain the following:
• A detailed explanation why services are either no longer reasonable and necessary or are otherwise no longer covered.
• A description of any applicable Medicare coverage rule, instruction, or other Medicare policy, including information about how the beneficiary may obtain a copy of the Medicare policy. (See instructions for the Detailed Notice of Discharge at Section 200.6.3, Exhibit 2)
• Facts specific to the beneficiary and relevant to the coverage determination that are sufficient to advise the beneficiary of the applicability of the coverage rule or policy to the beneficiary’s case.
• Any other information required by CMS.
Hospitals must follow requirements in Section 200.5.6 on Insertions in Blanks and Section 200.6. on Completing the Notices.
Full instructions for the Original Medicare, also known as Fee for Service (FFS), process are available in Section 200, of Chapter 30 of the Medicare Claims Processing Manual
42 C.F.R. §405.1205 Notifying beneficiaries of hospital discharge appeal rights.
(a) Applicability and scope. (1) For purposes of §§405.1204, 405.1205, 405.1206, and 405.1208, the term “hospital” is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals.
(2) For purposes of §§405.1204, 405.1205, 405.1206, and 405.1208, a discharge is a formal release of a beneficiary from an inpatient hospital.
(b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital.
(2) Content of the notice. The notice must include the following information:
(i) The beneficiary's rights as a hospital inpatient including the right to benefits for inpatient services and for post-hospital services in accordance with 1866(a)(1)(M) of the Act.
(ii) The beneficiary's right to request an expedited determination of the discharge decision including a description of the process under §405.1206, and the availability of other appeals processes if the beneficiary fails to meet the deadline for an expedited determination.
(iii) The circumstances under which a beneficiary will or will not be liable for charges for continued stay in the hospital in accordance with 1866(a)(1)(M) of the Act.
(iv) A beneficiary's right to receive additional detailed information in accordance with §405.1206(e).
(v) Any other information required by CMS.
(3) When delivery of the notice is valid. Delivery of the written notice of rights described in this section is valid if—
(i) The beneficiary (or the beneficiary's representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and
(ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section.
(4) If a beneficiary refuses to sign the notice. The hospital may annotate its notice to indicate the refusal, and the date of refusal is considered the date of receipt of the notice.
(c) Follow up notification. (1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge.
(2) Follow up notification is not required if the notice required under §405.1205(b) is delivered within 2 calendar days of discharge.
Questions regarding the IM and DND can be submitted at: https://appeals.lmi.org
