Kepro BFCC-QIO

Webinar Questions and Answers
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!

references for post-acute questions

post-acute care questions

When a Medicare Advantage (MA) resident receives a NOMNC, is it Kepro or the MA plan that makes the decision?

The MA plan determines when skilled coverage will end. The appeal is filed and processed through Kepro. Then our physician reviewers make a determination based on the information found in the beneficiary's medical record.
Is the patient/representative automatically given a copy of the records submitted to Kepro, or is it upon the request of the patient/representative?

Per the Centers for Medicare & Medicaid Services (CMS) guidelines, the beneficiary/representative must be given a copy of the signed NOMNC. The medical records are given upon request.
Must the documentation be on the NOMNC, or can it be in the progress notes of when a notice is given other than in person?

The Centers for Medicare & Medicaid Services (CMS) requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent and the provider cannot obtain the signature of the beneficiary's/enrollee's representative through direct personal contact.

The telephonic documentation can be annotated on the NOMNC or in the social worker/case manager notes. If the NOMNC is not annotated with the required information and such information is on a separate document, that document must be sent to the quality improvement organization (QIO).

Telephonic Documentation Information

If the NOMNC is being issued telephonically, the provider must document that ALL of the following information was provided to the person receiving the notification:

- The beneficiary’s name
- Date and time called
- Facility representative’s name
- Beneficiary representative’s phone number called
- Effective date
- Liability date
- QIO's name and phone number
- Appeal deadline
- What to do if they miss the deadline (Fee-for-Service [FFS] traditional Medicare will call Kepro to file}
- Medicare Advantage (MA) plan phone number, if applicable
- Signature/title/date of facility representative
If it must be on the NOMNC, can you provide the regulation source for this directive?
The Optional section of the NOMNC, found on page 2, can be used to document the above telephonic notification. While it is not required to be documented on the NOMNC, this section has been used by providers to demonstrate their efforts to make a proper telephonic notification.
As a home health provider, I am looking for some clarification on the physician certification phase of the appeal process. It has been our experience that we either do not receive the documentation that the appeal has gone on for physician certification, or we receive no notification on what the next steps are when the physician does not return the required documentation. When the physician does not make the deadline, is the agency able to discharge at that point without issuing another NOMNC?
In the Medicare Claims Processing Manual, Chapter 30 Section 260, the Centers for Medicare & Medicaid Services (CMS) writes "A beneficiary must obtain a physician certification stating that failure to continue home health or comprehensive outpatient rehabilitation facility (CORF) services is likely to place the beneficiary's health at significant risk." Without such a certification statement, a quality improvement organization (QIO) may not make a determination for service terminations in these settings.

The physician certification is a written statement from any licensed physician contacted by a beneficiary. This is a special certification required only in this expedited determination process for expedited determinations in home health and CORF settings.

A beneficiary may request an expedited determination from a QIO before obtaining this certification of risk. Once the QIO is aware of a review request, it will instruct the beneficiary on how to obtain the necessary certification from a physician.
Can you clarify whether a client must stay in the nursing facility until a second-level appeal is conducted and receives skilled services if the quality improvement organization’s (QIO’s) initial determination agreed with the NOMNC?
As outlined in the Medicare Claims Processing Manual, Chapter 30 Section 300 - 305, a beneficiary who is dissatisfied with a quality improvement organization (QIO) determination can request a reconsideration review by an independent review entity (IRE). For the traditional Medicare beneficiary, the IRE is not Kepro; however, Kepro is the IRE for the Medicare Advantage (MA) enrollee. When a beneficiary makes a timely request for an expedited determination, the provider may not bill the beneficiary for any disputed services until the IRE makes its determination. Beneficiary liability for continued services is based on the QIO's decision. Should the reconsideration reviewer uphold the initial review outcome, the beneficiary's liability date has not changed. It remains the date Kepro communicated to the beneficiary/provider/plan. However, should the reconsideration reviewer disagree with the initial review outcome, the beneficiary has no financial liability during the time needed to complete the reconsideration review.

As to whether the beneficiary/enrollee "must stay," that is not a decision the QIO is able to comment on. This is a beneficiary/enrollee decision given he/she may encounter financial liability for a continued stay.
Can providers email the NOMNC?
According to the Medicare Claims Processing Manual, Chapter 30 Section 260.3.8, "If both the provider and the representative agree, providers may send the notice by fax or email; however, providers' fax and email systems must meet the Health Insurance Portability and Accountability Act (HIPAA) of 1996 privacy and security requirements."
Does the NOMNC need to be delivered within 48 hours of the last covered date or within 72 hours?
According to the Centers for Medicare & Medicaid Services (CMS) Form Instructions for the NOMNC (CMS-10123), "The NOMNC must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily."
When a resident is not cognitively intact, is unable to be given the NOMNC, and has no family, responsible party, or friend, can a facility staff member accept the denial on the resident's behalf and appeal?
The Centers for Medicare & Medicaid Services (CMS) usually requires that notification to a beneficiary who has been deemed legally incompetent be made to an authorized representative of the beneficiary. Generally, an authorized representative is an individual who, under state or other applicable law, may make healthcare decisions on a beneficiary's behalf (e.g., the beneficiary's legal guardian or someone appointed in accordance with a properly executed durable medical power of attorney).

However, if a beneficiary is temporarily incapacitated, a person (typically a family member or close friend) whom the provider has determined could reasonably represent the beneficiary but who has not been named in any legally-binding document may be a representative for the purpose of receiving the notices described in this section. Such a representative should have the beneficiary's best interests at heart and must act in a manner that is protective of the beneficiary and the beneficiary's rights. Therefore, a representative should have no relevant conflict of interest with the beneficiary. It is Kepro's opinion that an employee of the facility issuing the NOMNC may be perceived as a conflict of interest (see Medicare Claims Processing Manual Chapter 30 Section 260.3.8).
Is Kepro required to give specific information, such as OT (occupational therapy) to continue or PT (physical therapy) to continue, because we typically get a blanket statement, PT, OT, ST (speech therapy) to continue, when not all disciplines were even in with the resident?
The NOMNC should indicate which skilled services are ending. Kepro cannot direct care. The statement “PT, OT, ST to continue” applies only to the service the beneficiary is currently receiving.
If we are sending the NOMNC via certified mail due to being unable to contact the resident’s representative and the resident has dementia, what date should be noted as the last covered day? Is it still the 48-hour time frame, or is it longer due to the mailing process?
If the NOMNC must be delivered to the beneficiary to a representative not living with the beneficiary, the provider is not required to make off-site, in-person notice delivery to the representative. The provider must complete the NOMNC as required and telephone the representative at least two days prior to the end of covered services.

If the provider chooses to communicate the information in writing, a hard copy of the NOMNC must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g., FedEx, UPS). The burden is on the provider to demonstrate that timely contact was attempted with the representative and that the notice was delivered.
If issuing over the phone was successful, do we need to mail the NOMNC via certified mail, or can we mail it via regular mail only?
A hard copy of the NOMNC must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g., FedEx, UPS). The burden is on the provider to demonstrate that timely contact was attempted with the representative and that the notice was delivered (see Medicare Claims Processing Manual, Chapter 30 Section 260.3.8).
If the NOMNC is issued and the date of discharge changes by one day due to a continued skill, is a new NOMNC required with a new 48 hours, or can the notice that was already issued be modified with the additional day of coverage?
As outlined in the Medicare Claims Processing Manual, Chapter 30 Section 260.3.7, if the initial NOMNC was delivered to a beneficiary and the Effective Date was changed, the provider may amend the notice to reflect the new date. The newer Effective Date may not be earlier than the Effective Date of the original notice except in those cases involving the abrupt end of services as discussed in Section 260.3.4.

The beneficiary must be verbally notified as soon as possible after the provider is aware of the change. The amended NOMNC must be delivered or mailed to the beneficiary and a copy retained in the beneficiary's file. If an expedited determination is already in progress, the provider must immediately notify the quality improvement organization (QIO) of the change and provide an amended notice to the QIO.
How far in advance can a skilled nursing facility NOMNC be issued? Is it only 48 hours before discharge?
The NOMNC may be delivered earlier than two days preceding the end of covered services. However, delivery of the notice should be closely tied to the impending end of coverage, so a beneficiary will more likely understand and retain the information regarding the right to an expedited determination (see the Medicare Claims Processing Manual, Chapter 30 Section 260.3.4.).

For valid NOMNCs with an Effective Date that is three or four days in the future from the date the case is pulled for completion, Kepro will “pend” or hold the case review until one day prior to the Effective Date. One day prior to the Effective Date, Kepro will call for additional (more current) medical records. The facility will be informed that they have until close of business to submit the most current medical records. For Effective Dates that are five or more days in the future, Kepro will invalidate the NOMNC. The nurse will notify the beneficiary/representative, facility, and Medicare Advantage (MA) plan (if applicable) of invalidation.
If the beneficiary stays in the facility during a reconsideration and receives services, is the beneficiary responsible for costs if the reconsideration continues to agree with the initial NOMNC?
When a beneficiary makes a timely request for an expedited determination, the provider may not bill the beneficiary for any disputed services until the independent review entity (IRE) makes its determination. The beneficiary liability for continued services is based upon the quality improvement organization's (QIO's) decision. Should the reconsideration reviewer uphold the initial review outcome, the beneficiary liability date hasn't changed. It remains the date that Kepro communicated to the beneficiary/provider/plan. However, should the reconsideration reviewer disagree with the initial review outcome, the beneficiary has no financial liability during the time needed to complete the reconsideration review (see Medicare Claims Processing Manual, Chapter 30 Section 300 - 305).
If we cannot get a hold of a family member, how many attempts/follow-up calls do we have to make when issuing a NOMNC?
Kepro cannot direct how many attempts should be made.
Where would you document on the NOMNC when someone refuses to sign?
The Optional section of the NOMNC is available for the provider to use as needed. This section could be used to document those situations where the beneficiary or his/her representative refuses to sign the NOMNC.
Where do we get a copy of the phone notification form?
Telephonic Documentation Information

If the NOMNC is being issued telephonically, the provider must document that ALL of the following information was provided to the person receiving the notification (see Medicare Claims Processing Manual, Chapter 30 Section 260.3.8):

- The beneficiary’s name
- Date and time called
- Facility representative’s name
- Beneficiary representative’s phone number called
- Effective date
- Liability date
- Quality improvement organization's (QIO's) name and phone number
- Appeal deadline
- What to do if they miss the deadline [Fee for Service (FFS), traditional Medicare will call Kepro to file]
- Medicare Advantage (MA) plan phone number, if applicable
- Signature/title/date of facility representative
We've had patients call for an appeal after their deadline (for example, filing for an appeal on the day of discharge). Why was this processed as an appeal? The patient was late in appealing, so I was very confused as to why this situation was treated as an appeal.
As outlined in the Medicare Claims Processing Manual, Chapter 30 Section 260.4.3., if the beneficiary makes an untimely request to the quality improvement organization (QIO), the QIO will accept the request for review, but it is not required to complete the review within its usual 72-hour deadline. The QIO will make a determination as soon as possible upon receipt of the request.

Beneficiaries have up to 60 days from the Effective Date of the NOMNC to make an untimely request to a QIO. When the beneficiary is still receiving services, the QIO must make a determination and notify the parties within seven days of receipt of the request. When the beneficiary is no longer receiving services, the QIO will make a determination within 30 days of the request.

Currently, Medicare Advantage enrollees must call the health plan when they are requesting an appeal after 12 pm on the day before the Effective Date.
If the NOMNC was given and it goes to physician review, what is the process if there is no physician response in the allotted 60 days?
If this is regarding a home health appeal pending the physician’s certification, Kepro will not process an appeal if that certification is not received in the required time frame. This applies only to home health appeals when the beneficiary has Fee-for-Service (FFS), traditional Medicare.
What should we list in the skilled nursing area on the NOMNC for Part B therapy? Should we list the therapy they are being discharged from?
If the beneficiary is only receiving Part B services, please document this on the NOMNC. For example, Part B physical therapy only.
If a beneficiary wins an appeal due to a technicality, is the managed care provider liable to pay for the dates of service won during the appeal? For example, if the last covered day (LCD) was November 22 and they win, and a new NOMNC is issued on November 24 with a last covered date of November 26, does the insurance provider have to pay for November 23 through November 26?
If the decision to end services is overturned by Kepro, the beneficiary has no liability until a new NOMNC is issued with a new LCD.
When issuing a Part B NOMNC for Part B therapy services, do you use the same NOMNC for managed care/Part A services, and do the same appeal rights apply with the same process?
Yes, the same NOMNC is used for Part B services. Kepro only processes Part B appeals for beneficiaries with Fee-For-Service (FFS), traditional Medicare. Kepro does not process appeals for Part B services when the beneficiary has a Medicare Advantage (MA) plan. Part B services are considered outpatient services and are contractual between the plan and the provider for the beneficiary to receive these services.
Do you still need to issue a new NOMNC if the original planned discharge date was moved due to the visit not being made on the original discharge date?
If home health services are being provided less frequently than daily, the notice must be delivered no later than the next to last visit before Medicare-covered services end. The NOMNC may be delivered earlier than two days preceding the end of covered services. However, delivery of the notice should be closely tied to the impending end of coverage, so a beneficiary will more likely understand and retain the information regarding the right to an expedited determination.
Why do post-acute facilities only get a fax and not a phone call?
As outlined in the Medicare Claims Processing Manual, Chapter 30 Section 260.5.2, when the quality improvement organization (QIO) receives a request from a beneficiary, the QIO must immediately notify the provider of services that a request for an expedited determination was made. If the request is received after normal working hours, the QIO should notify the provider as soon as possible on the morning after the request was made.

Kepro uses fax transmission to notify the provider of a pending appeal and the results.
Should records be provided to the patient on the same day that the agency submitted the records to Kepro, or is there a certain timeline for that?
As outlined in the Medicare Claims Processing Manual, Chapter 30 Section 260.4.4, providers are to "furnish the beneficiary, at their request, with access to or copies of any documentation it provides to the quality improvement organization (QIO). The provider may charge the beneficiary a reasonable amount to cover the costs of duplicating and delivering the documentation. The documentation must be provided to the beneficiary by close of business of the first day after the material is requested."
What is the best way to show that post-acute records are complete if therapy was discontinued in weeks prior and Kepro does not receive updated therapy notes?
Please include the discharge summary if the beneficiary has been discharged from therapy.
It is very difficult to navigate through the responses received from the call center, especially when a unique situation arises. Is there an escalation process that an organization can utilize rather than awaiting a call back from a nurse reviewer, which usually comes after hours?
Kepro's appeals team has developed internal service level agreements for escalated calls. When a provider has a unique situation or needs clarity regarding a recent call, we ask that provider to call the toll-free number and request to speak with a nurse. These escalated calls should receive a return call within two hours.
We have received faxes late in the afternoon from Kepro and were told we have until the end of that day to upload all the clinical information. I thought we had 24 hours to upload this information.
When a provider is notified by a quality improvement organization (QIO) of a beneficiary request for an expedited determination, the provider must:

- deliver the beneficiary a Detailed Explanation of Non-Coverage (DENC) (see Medicare Claims Processing Manual Chapter 30 Section 260.4.5) by close of business the day they are notified.
- supply the QIO with copies of the NOMNC and DENCs by close of business on the day of QIO notification.
- supply all information, including medical records, requested by the QIO (see the Medicare Claims Processing Manual, Chapter 30 Section 260.4.4).
Doesn't Kepro notify the Medicare Advantage (MA) plan of an appeal? We've had several skilled nursing facility appeals where the MA plan was not notified of the appeal.
When the quality improvement organization (QIO) receives a request from a beneficiary, the QIO must immediately notify the provider of services that a request for an expedited determination was made. If the appeal request is from a MA enrollee, the health plan will also be notified of the request via fax transmission.
According to the Medicare Benefit Manual, tube feeding is considered a skill. However, we have been denied by Kepro for this as a skilled service.
According to the Medicare Benefit Manual, Chapter 8 Section 30, enteral feeding (i.e., tube feedings) that comprise at least 26 percent of daily calorie requirements and provide at least 501 milliliters of fluid per day is considered skillable.
We had a Medicare Part B that was not upheld because of missing medical records. When we called, we were told that it did not include the resident's current level of function. This was a resident who was being seen by therapy for the application of a splint that had been applied, so therapy got it. What documentation and by what discipline can we include to cover this in the future, as we included everything on the checklist?
Please include this information in the therapy notes. It should be clearly documented as to what treatment the beneficiary is receiving. If services have ended before the appeal is requested and before the seven-day time frame, please include a discharge summary for that service.
What should providers do if the patient refuses to call to appeal the discharge and also refuses to discharge?
In the post-acute setting, the NOMNC outlines when the beneficiary can become financially liable for all continued skilled services. This is the day after the Effective Date on the notice.
What are the regulations as it affects the facility when a beneficiary’s representative does not answer our calls or return our messages? Also, what should we do if the representative refuses to sign the letter?
When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee's medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee's liability starts on the second working day after the provider's mailing date (see Form Instructions document).

The Centers for Medicare & Medicaid Services (CMS) outlines that a hard copy of the NOMNC must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery such as FedEx, UPS, etc. (see Medicare Claims Process Manual, Chapter 30 Section 260.3.8).
What do you use for a determination of a cognitively impaired patient, BIMS (Brief Interview for Mental Status) and at what level?
Kepro makes its determination based on the diagnosis found in the medical records. The documentation in the skilled nursing and therapy notes will speak to the mental state of the beneficiary. A BIMS score of 12 or less shows moderate to severe cognitive status.
Who should we reach out to if we notice an error made in the review? For example, in a skilled nursing facility patient, the functional values listed were from the initial evaluation and not from the most current therapy notes.
If you find an error that was made on an appeal, we ask that you notify Kepro as soon as possible for it to be corrected. If you receive notification of the outcome of the appeal after business hours, please contact Kepro first thing on the following calendar day. Please call the toll-free number and ask to speak with a nurse.
During a second-level appeal, the resident can remain in the facility and receive therapy. Are they required to stay in the facility during the second-level appeal?
The beneficiary has a right to remain in the facility. He/she does not necessarily have financial protection as the continued care is being provided after the Effective Date of the NOMNC. If the beneficiary decides to leave the facility during the reconsideration process, Kepro will process the reconsideration but only if the beneficiary leaves the facility after the date of liability.
If the determination is in favor of the resident in a skilled nursing facility due to a technical denial, such as invalid notice/notification or missing medical records submitted to Kepro, is the facility held liable for those days until notice is reissued, or can the days be billed to Medicare for services?
As outlined in Sections 260.3.6 and 5.3 of the Medicare Claims Processing Manual, the quality improvement organization (QIO) must validate that the NOMNC included the required elements. If the QIO determines that a provider did not deliver a valid NOMNC to a beneficiary, the provider is financially liable for continued services until two days after the beneficiary receives a valid notice or until the Effective date of the valid notice, whichever is later.
Can a provider bill a patient while an appeal is being processed?
When a beneficiary makes a timely request for an expedited determination, the provider may not bill the beneficiary for any disputed services until the independent review entity (IRE) makes its determination. The beneficiary liability for continued services is based on the QIO's decision (see the Medicare Claims Processing Manual, Chapter 30 Section 300.5 - Coverage During an Expedited Reconsideration).
There are instances in which clients have lost the first-level appeal. However, the nursing facility has not been informed of a second-level appeal. Therefore, skilled services have ended. Several days later, we were told that the beneficiary requested a second-level appeal, and it was overturned and to continue coverage. During that time, the beneficiary has not received a skilled service, yet we are supposed to bill Medicare Part A for days they did not receive a skilled service.
Billing questions are outside of Kepro's scope of review responsibility. We would recommend the provider reach out to their respective Medicare Administrative Contractor for billing guidance. Kepro determines the financial liability for the beneficiary and whether skilled services should continue.
When we believe a beneficiary has been taken off their coverage inappropriately, is there better information to send, such as physician's statements, therapists, etc.?
The burden of proof is such that the beneficiary is ready for the discontinuation of skilled services rests on the provider. Kepro would encourage providers to submit all necessary medical information that supports its decision to discontinue skilled services.

references for acute care questions

Beneficiary Notices Initiative - the official repository for all notices given to a Medicare beneficiary and/or enrollee)
Important Message from Medicare (IM) Form Instructions
Medicare Claims Processing Manual Chapter 30 Section 200 - expedited determination of inpatient hospital discharges

acute care questions

If the representative states that he/she does not want a copy of the IM or the Detailed Notice of Discharge (DND), can we document that and not provide a copy?
Revision: 3/27/2024

Section §200.3.3 of the Medicare Claims Processing Manual, titled Hospital Delivery of the IM, guides the hospital community regarding the delivery of the IM notice to beneficiaries and/or their representatives. Hospitals must deliver the IM to all beneficiaries eligible for the expedited determination process, per §200.2.

An IM must be delivered even if the beneficiary agrees with the discharge. The hospital must ensure that the beneficiary or representative signs and dates the IM. This is done to demonstrate that the beneficiary or representative received the notice and understood its contents.

If a hospital elects to issue an IM that has been viewed on an electronic screen before signing, the beneficiary must be given the option to request a paper issuance if that is preferred.

Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the IM, as specified in §200.3.9. The required beneficiary-specific information must be inserted at the time of notice delivery.

Kepro acknowledges that CMS has not provided guidance regarding individuals who decline a copy of the IM notice. Historically, best practice has been to annotate the IM notice in the Optional section. This gives proof that the hospital attempted to provide the required information, but the beneficiary or representative refused to sign the document. We would suggest a similar process for those beneficiaries or their representatives who decline to receive a copy of the document.
Are home hospice and residential hospice discharges both excluded from needing an IM?
Medicare beneficiaries who are hospital inpatients have a statutory right to appeal to a quality improvement organization (QIO) for an expedited review when a hospital, with physician concurrence, determines that inpatient care is no longer necessary (see the Medicare Claims Processing Manual, Chapter 30, Section 200).

Residential and at-home hospice care is not identified as “hospital” and would be excluded from the IM process. However, should residential and at-home hospice care be discontinued, it would likely require the provider to issue a NOMNC.
Is there any guidance on whether the discharge order needs to be in place at a hospital before the appeal is made?
Revision: 3/27/2024

As noted in the Medicare Claims Processing Manual, Chapter 30, §200.3.1 “Once the discharge date is planned, a hospital does not need discharge orders in advance of delivering the IM.”
For an acute reconsideration, is there a time frame for the patient to request it?
A beneficiary who chooses to exercise the right to an expedited reconsideration must submit a request to the appropriate independent review entity (IRE) (quality improvement organization [QIO] is the IRE) in writing or by telephone no later than noon of the calendar day following the initial notification (whether by telephone or in writing) of the QIO’s determination (see Medicare’s Claims Processing Manual, Chapter 30, Section 300.1).
What should providers do if the patient refuses to call to appeal the discharge and also refuses to discharge?
A beneficiary may choose to remain in the hospital beyond the last day of coverage but may be liable for services after that day. The hospital should issue a Hospital-Issued Notice of Non-coverage (HINN 12) to inform the beneficiary of potential liability (see the Medicare Claims Processing Manual, Chapter 30, Section 200.6.2).
What are the key factors you are looking at for a safe discharge plan? What if a member needs a higher level of care, but there is no movement on finding a discharge plan?
If the discharge plan is for the beneficiary to go to a skilled nursing facility, document that a bed has been secured. If the discharge plan is for the beneficiary to go home, are they safe to go home alone? If the plan is for home health, document that home health care has been arranged. Is there a need for durable medical equipment supplies in the home? Have they been ordered? Will they arrive prior to the beneficiary’s discharge home? This documentation is needed for Kepro to decide on a safe discharge plan. Any arrangements needed for the discharge must be confirmed and not pending when the appeal is filed. Beneficiaries who are discharged to a higher level of care do not have appeal rights because they are going to a higher level of care. This is the same for beneficiaries discharging from an acute inpatient stay to an acute inpatient rehabilitation. This is the same level of care, and they have no appeal rights. Kepro will close these appeals and notify all parties.