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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!

Update:

New Process for Medical Records Submitted to KEPRO for Appeals
KEPRO has added a bar code to all appeal medical record fax requests sent to healthcare providers and Medicare Advantage health plans. These bar codes directly correlate to the case ID associated with each appeal. KEPRO kindly requests that all providers include the fax request document with this bar code when submitting medical records to KEPRO. If there are multiple medical records or batches of records, please include the fax request document with the bar code as the first sheet of each batch. We anticipate that the use of these bar codes will provide a more efficient process when attaching medical records to the appeal review. It is anticipated that this modification could reduce the time needed for appeal reviews and allow KEPRO to provide a final determination sooner.


Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers. KEPRO provides two types of appeal reviews: Hospital Discharge Appeals and Expedited Determinations.

Hospital Discharge Appeals
On November 27, 2006, the Centers for Medicare & Medicaid Services (CMS) published a final rule, CMS-4105-F: Notification of Hospital Discharge Appeal Rights. Beginning July 1, 2007, hospitals must deliver a revised version of the Important Message from Medicare (IM) to inform all Medicare beneficiaries who are hospital inpatients, including MA enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible beneficiaries about their hospital discharge appeal rights.

CMS has provided guidelines regarding the delivery of the initial follow-up IM along with communication specifications regarding the size of the notice. Beneficiaries who choose to appeal a discharge decision will receive a more detailed notice outlining the rationale and applicable Medicare Coverage guidelines for such a decision.

Hospital Requested Review (HRR)

HINN 10, also known as the Notice of Hospital Requested Review (HRR), should be issued by hospitals to beneficiaries in 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 beneficiaries in Fee-For-Service Medicare are required to notify beneficiaries 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 Generic Notice to beneficiaries to alert them that a Medicare-covered item or service is ending and give beneficiaries 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.

Under the MA program, HHAs, SNFs, and CORFs are required to provide a Notice of Medicare Non-Coverage to beneficiaries to alert them that a Medicare covered item or service is ending and give enrollees 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.

Contact Information
For Area 2, please fax medical records to: 844-834-7129
For Area 3, please fax medical records to: 844-878-7921
For Area 4, please fax medical records to: 844-834-7130

Area 2 includes the following states: District of Columbia, Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia

Area 3 includes the following states: Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, North Dakota, New Mexico, Oklahoma, South Dakota, Tennessee, Texas, Utah, Wyoming

Area 4 includes the following states: Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin

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