Responding to a Beneficiary’s Appeal

Under our Quality Improvement Organization (QIO) contract with Medicare, Qualis Health is responsible for responding to Idaho and Washington Medicare beneficiaries' appeals related to an impending discharge or termination of services.

In many cases, healthcare facilities are required to give advance notice to Medicare beneficiaries and to members of Medicare Advantage plans before their care is terminated. This notice also informs patients of their right to appeal.

Everyone Needs to Act Quickly
After receiving the notice, Medicare beneficiaries must act quickly to begin the appeal process. To comply with federal guidelines, Qualis Health must process beneficiary appeals within a very short timeframe. Finally, to avoid potential liability for patient charges, healthcare facilities must also respond to our requests for information in a timely manner. We typically need the following records faxed to us:

• The patient's medical record
• The completed Advance Notice, Detailed Notice, or Important Message

(Upon request by the beneficiary, the healthcare facility must provide him or her with copies of any information sent to Qualis Health during an appeal.)

When we receive the patient's records, we will assign an independent physician to review the case and make a decision. Our review team will notify the beneficiary, provider, patient's physician, and financial intermediary of the outcome right away.

If the beneficiary disagrees with the appeal outcome, s/he may request a reconsideration. Instructions for requesting a reconsideration will be provided to the beneficiary at the time we communicate our initial decision.

Potential Liability for Care Provided While the Appeal is in Process
Reviews are conducted 365 days a year, during the hours of 8:00am to 4:30pm local time. To limit your potential liability for patient charges, it is essential to provide Qualis Health with the medical record as soon as possible.

Liability in Acute Inpatient Appeals
Beneficiaries will not be liable for charges related to their care until the later of:

• Noon the day following the notification of our decision, or
• The scheduled discharge date

The beneficiary will be able to remain in the hospital until we have received the medical records and made a decision.

Liability in All Other Settings
If we do not receive the medical records by the requested time, we will overturn the discharge and the healthcare provider must issue another Advance Notice. In these cases, beneficiaries will not be liable for charges related to their care until the discharge date specified in the re-issued Advance Notice.