Fast appeals

What do I need to know before I ask for a fast appeal?

In a hospital: Within 2 days of your admission and prior to your discharge, you should get a notice called "An Important Message from Medicare about Your Rights." This notice is sometimes called the Important Message from Medicare or the IM. If you don't get this notice, ask for it.

If the hospital gives you the IM more than 2 days before your discharge day, it must give you a copy of your original, signed IM or provide you with a new one (that you must sign) before you're discharged.

In other settings: You should get a notice called "Notice of Medicare Non-Coverage" at least 2 days before covered services end. If you don't get this notice, ask for it.

Both notices will include, as applicable:

• Your right to get all medically necessary hospital services
• Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and to know who will pay for them
• Your right to get the services you need after you leave the hospital
• Your right to appeal and the steps for appealing
• The circumstances under which you will or won’t have to pay for services you get after the coverage end date on your notice
• The date your covered services will end
• Information on your right to get a detailed notice about why your covered services are ending
• Your right to a fast appeal and information on how to contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your state to request a fast appeal

How do I ask for a fast appeal?

In a hospital: Follow the directions on the Important Message from Medicare no later than the day you're scheduled to be discharged from the hospital.

If you ask for your appeal within this time frame, you can stay in the hospital while you wait to get the BFCC-QIO's decision. You won't have to pay for your stay (except for applicable coinsurance or deductibles). The hospital can't force you to leave before the BFCC-QIO reaches a decision. If you miss the deadline for a fast appeal, you can still ask the BFCC-QIO to review your case, but different rules and time frames apply, and you might be responsible for the cost of the hospital stay past the original day the hospital tries to discharge you.

If you're in a Medicare Advantage Plan, you can ask your plan for an appeal, but different rules apply.

In other settings: Follow the instructions on the "Notice of Medicare Non-Coverage" no later than noon the day before the termination date listed on the notice. 

If you miss the deadline for requesting a fast appeal from the BFCC-QIO, you can request a fast reconsideration from your plan, but services will only be covered if there's a decision issued in your favor.

What will happen during the BFCC-QIO's review?

In a hospital: If you have Original Medicare, the BFCC-QIO will notify the hospital. If you have a Medicare health plan, the BFCC-QIO will notify your plan and the hospital. Then, by noon the day after the BFCC-QIO notifies the hospital (or your plan), the hospital will give you a "Detailed Notice of Discharge."

In other settings: The BFCC-QIO will notify the provider. Then, by the end of the day that the provider gets the notice from the BFCC-QIO, the provider will give you a "Detailed Explanation of Non-Coverage." Both notices will include:

• Why your services are no longer reasonable and necessary or are no longer covered
• A description of the applicable Medicare coverage rule or policy, including information on how you can get a copy of the policy
• How the applicable coverage rule or policy applies to your specific situation

You can also ask for copies of any of the materials that were sent to the BFCC-QIO.

Then the BFCC-QIO will:

• Ask why you believe coverage for the services should continue
• Look at your medical records and the information provided by the hospital (or your plan)
• Make a decision:
  • In a hospital: Within one day of getting the requested information.
  • In other settings: By close of business the day after it gets the information it needs to make a decision

If the BFCC-QIO decides that your services are ending too soon:

In a hospital:

• If you have Original Medicare: Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles).
• If you have a Medicare health plan: Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles) if your plan previously authorized coverage of the inpatient admission, or the inpatient admission was for emergency or urgently needed care.

You may need to appeal the denial of coverage for your plan to pay if your plan never authorized the inpatient admission, or the inpatient admission wasn’t for emergency or urgently needed care.

In other settings: Depending on your care needs, Medicare may continue to cover your Skilled Nursing Facility, Home Health Agency, Comprehensive Outpatient Rehabilitation Facility (CORF), or hospice services (except for applicable coinsurance or deductibles).

If the BFCC-QIO decides that your services should end:

In a hospital: If you met the deadline for asking for a fast appeal, you won't be responsible for paying the hospital charges (except for applicable coinsurance or deductibles) incurred through noon of the day after the BFCC-QIO gives you its decision. If you get any inpatient hospital services after noon of that day, you may have to pay for them.

In other settings: You won't be responsible for paying for any SNF, HHA, CORF, or hospice services provided before the coverage end date on the "Notice of Medicare Non-Coverage." If you continue to get services after the coverage end date, you may have to pay for those services.

Contact your BFCC-QIO for help

You can also contact your BFCC-QIO or your state’s survey agency to ask questions, report complaints about the quality of care you or a loved one got for a Medicare-covered service, or if you aren’t satisfied with your provider’s response to your concern. You may need to start a separate appeals process for any items or services you get after the decision to end services.