NY Manual
SHP Manual

New York Provider Manual
XIII-E Appointment of Representative Statement and Form | XIII-G Important Message from Medicare About Your Rights

Appendix XIII-F — Detailed Notice of Discharge

OMB Approval No. 0938-1019
Patient Name:                                                                                                                       
Patient ID Number:                                                                                                                               
Date: Issued:                                                          
You have asked for a review by the Quality Improvement Organization (QIO), an independent reviewer hired by Medicare to review your case. This notice gives you a detailed explanation about why your hospital and your managed care plan (if you belong to one), in agreement with your doctor, believe that your inpatient hospital services should end on ____________________________. This is based on Medicare coverage policies listed below and your medical condition. This is not an official Medicare decision. The decision on your appeal will come from your Quality Improvement Organization (QIO). 
·     Medicare Coverage Policies:
Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished in another setting. (Refer to 42 Code of Federal Regulations, 411.15 (g) and (k).)
____ Medicare Managed Care policies, if applicable (check below): 
____  In response to your diagnosis, your physician developed a comprehensive care plan designed to specifically address your medical condition. Based on your progress and recovery thus far, your physician is confident that a sufficient level of inpatient services have been provided and has not requested additional inpatient days be added to your care plan.
____  Per Medicare guidelines, any additional inpatient days would need to be outlined under a plan of care and approved by a physician. As there is no current physician order for additional inpatient days, no additional services will be covered.
____ Other
Specific information about your current medical condition:
Some or all of the following factors no longer exist:
____  Severity of the signs and symptoms exhibited by the patient;
____  The medical predictability of something adverse happening to the patient;
____  The need for inpatient diagnostic studies;
____  Diagnostic and therapeutic services for medical diagnosis, treatment, and care are no longer medically necessary.
If you would like a copy of the documents sent to the QIO, or copies of the specific policies or criteria used to make this decision, or if you need help understanding the content of this notice, please call our Medical Management department at 1-888-394-4327 (TTY 1-800-662-1220), Monday–Friday, 8am–6pm.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1019. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 
CMS 10066 (approved 5/2007)                                                                                             H3359 UMD07_11 12/07