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Appeals We are the Medicare Quality Improvement Organization, working to improve the quality of care for Medicare beneficiaries. Our site offers beneficiary and family-centered care information for providers, patients, and families. Welcome! |
related links
- Overview
- Beneficiary Complaints
- Other Reviews
- Medical Record Electronic Submission
- Educational Resources
- Physician Acknowledgement Monitoring
- QIO Liaison
- Memorandum of Agreement
- Update Your Contact Information
- Become a Peer Reviewer
- Case Status Check
- Appeals Process Flow Chart (PDF)
contact kepro
Click below to get Kepro's telephone number, fax number and mailing address for your state.
case status
As always, you can check the status of an appeal that has been started online.
hospital discharge appeals
a new process for hospital discharge appeals
Some hospital discharge appeals are filed due to concerns with the discharge planning process rather than issues with the actual discharge. To address these concerns, the Centers for Medicare & Medicaid Services (CMS) has tasked the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) with collaborating closely with healthcare facilities to ensure that Medicare beneficiaries with Original Medicare and/or their representatives clearly understand their home discharge plans.
Starting May 1, 2024, when initiating a hospital discharge appeal, Medicare beneficiaries with Original Medicare and their representatives who call Kepro regarding discharge planning concerns will be transferred to the Immediate Advocacy (IA) team. This team will review the concerns, identify any gaps or misunderstandings, and determine if additional guidance is needed. While Kepro’s IA team engages with providers for direct dialogue, the formal process for the appeal will continue unchanged, ensuring that both processes occur simultaneously without impacting the overall timeline.
If further assistance is required, Kepro’s IA team will engage the hospital's case management team in a discussion to address any unresolved issues. This may involve a three-way call between Kepro, the beneficiary (or their representative), and the hospital case manager. If an in-person meeting is preferred, Kepro staff will participate remotely by phone only.
This collaborative approach aims to help beneficiaries and their representatives understand and complete their discharge plans. If discussions successfully clarify the discharge plan and resolve concerns, beneficiaries may request that Kepro stop the appeal. In such cases, Kepro will consider the appeal resolved and inform the hospital accordingly. Both the beneficiary/representative and provider will also receive a letter from Kepro at the conclusion of this process.
cms final rule
On November 27, 2006, CMS published a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. Beginning July 1, 2007, hospitals must deliver the Important Message from Medicare (IM) to inform all Medicare inpatients, including Medicare Advantage enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible patients about their hospital discharge appeal rights.
Hospitals are required to give a Detailed Notice of Discharge (DND) to patients who choose to appeal a discharge decision. The DND outlines the specific reasons for discharge and applicable Medicare coverage guidelines.
Current versions of the Important Message from Medicare (IM), Form CMS-10065, and the Detailed Notice of Discharge (DND), Form CMS-10066, are posted on the Hospital Discharge Appeal Notices page of the CMS website under Downloads.
hospital requested review (hrr)
HINN 10, also known as the Notice of Hospital Requested Review (HRR), should be issued by hospitals to patients with Original Medicare whenever a hospital requests a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) review of a discharge decision without physician concurrence. To initiate an HRR, the hospital staff should call Kepro, and then electronically send the medical record. HRRs are completed Monday - Friday and will be completed within two business days of the receipt of all pertinent information requested.
expedited determinations
Home health agencies (HHAs), skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and hospices with patients that have Medicare are required to notify them of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.
HHAs, SNFs, hospices, CORFs, and swing beds (under instruction) are required to provide a Notice of Medicare Non-Coverage to Medicare patients (including those patients with a Medicare Advantage plan) to alert them that a Medicare-covered item or service is ending and give patients the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Notice is given when the BFCC-QIO review is requested in order to provide more explanation on why coverage is ending.
