Hospital Discharge Appeal Process

If the Medicare Advantage member is dissatisfied with the discharge plan:

1. A member who chooses to exercise their right to an immediate review must submit a request to the Quality Improvement Organization (QIO), following the instructions on the An Important Message from Medicare About Your Rights notice. 
2. If Blue Cross and Blue Shield of Nebraska (BCBSNE) is driving the discharge, the QIO notifies the health plan that the member has requested an immediate review.  
3. BCBSNE or the facility is responsible for delivering to the member a Detailed Notice of Discharge as soon as possible, but no later than noon of the day after the QIO’s notification. The standardized notice includes a detailed explanation of the reason that services are either no longer reasonable or necessary or are otherwise no longer covered. The Detailed Notice of Discharge must be completed and submitted by the entity that determines that covered services are ending, whether it is BCBSNE or the facility.  
4. BCBSNE or the facility must supply any other information that the QIO needs to make its determination as soon as possible but no later than the close of business on the day that BCBSNE notifies the facility of the request for information. This includes copies of both the An Important Message from Medicare About Your Rights notice and the Detailed Notice of Discharge and written records of any information provided by phone.  
5. The QIO makes a determination and notifies BCBSNE, the member, the hospital and the physician of its determination within one calendar day after it receives the requested information.  
6. BCBSNE continues to be responsible for paying the costs of the member’s stay until noon of the next calendar day following the day that the QIO notifies the member of their coverage decision.  
7. If the member is late or misses the noon deadline to file for an immediate review by the QIO, they may still request an expedited appeal from BCBSNE.