MEDICAID ADMINISTRATIVE MEMORANDUM # 2006-07
TO:
IPRO Liaison
FROM:
Theodore O. Will
Chief Executive Officer
DATE:
October 16, 2006
SUBJECT:
IPRA DISCHARGE REVIEW CRITERIA
IPRO CONTACT:
Doreen Walz, RN, Assistant Director, Ext. 444
cc:
Gerald J. Stenson
Hospital Administrator
IPRO has served as the New York State Department of Health Medicaid Independent Professional Review
Agent (IPRA) since December 17, 1987. At this time, IPRO is issuing this memorandum to restate the IPRO
IPRA Discharge Review Process.
The following is attached to this memorandum:

IPRO/IPRA Discharge Review Procedures – The procedures are based on three (3) potential
scenarios, based on who initiates the review, i.e., the hospitalized patient or patient representative, the
discharged patient or patient representative or the hospital when the attending physician disagrees with
the discharge, the discharge plan or notice.

Sample Documents:
Discharge Notices – There are three New York State Hospital Review and Planning Council
approved notices:
1. For patients reimbursed under the case payment system (including patients on ALC),
2. For patients reimbursed on a per diem basis, i.e. patients in exempt units,
3. For cases where the hospital indicates the patient is ready for discharge and the attending
physician disagrees.

Department of Health letter to Greater New York Hospital Association which contains the list of all IPRA
Agents, a Question and Answer document on discharge reviews, Dear Administrator Letter dated
December 30, 1987, Timing of Discharge Notice-5 Examples. (Attachment A).

Department of Health Memorandum 87-96 dated December 17, 1987 on Discharge Review Program.
(Attachment B)
The IPRA Discharge regulations can be found on the New York State Department of Health Website
http://www.health.state.ny.us/nysdoh/phforum/nycrr10.htm click on “Search Title 10” and type in 405.9.
TOW/DWalz/CAIDAdminMemo2006-07
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Administrative Memorandum #2006-07
October 16, 2005
Page 2 of 15
PATIENT RIGHTS – AS SET FORTH IN THE BOOKLET “YOUR RIGHTS AS A HOSPITAL PATIENT”
The discharge review process for Medicaid patients begins on admission with the issuance of the “Your Rights
as a Hospital Patient in New York State” booklet. This booklet states the patient’s rights as a hospital patient,
how to make a discharge appeal if the patient feels that they are being asked to leave the hospital too soon, the
right to have a written discharge plan and who to call for assistance/help from the Independent Professional
Review Agent (IPRA). (The “Your Rights as a Hospital Patient in New York State” booklet can be found on the
New York State Department of Health website at www.health.state.ny.us. Once you are in the DOH home page
go to Site Contents and click on Hospitals Nursing Home and other Health Care Providers, then click on
Hospitals, then click on Patients Rights, then click on “Your Rights as a Hospital Patient in New York State and
then go to the bottom of the page and click on PDF version to view booklet.)
IPRO/IPRA REVIEW PROCEDURES
There are four issues that should be highlighted concerning the IPRA review procedures:
1. Psychiatric Unit Patients - The Office of Health Systems Management (OHSM) has indicated that patients
in psychiatric units are exempt from the Discharge Review Program. Hospitals are to follow the
discharge requirements in the Mental Hygiene Law for Psychiatric Unit patients.
2. Court Remand Patients - OHSM has indicated that the hospital must follow the court’s instructions for
court remand cases. Court remand cases have not been exempted from the Discharge Review Program;
however, no decision can overturn the court’s determination.
3. Prisoners – Public Health Law 2803-1 does not exempt prisoners from the Discharge Review Program
requirements. Therefore, all requirements contained in the Discharge Review Program apply to the
prisoner as well as the non-prisoner population.
4. Alternate Level of Care Patients – Non-Medicare patients on Alternate Level of Care (ALC) have the right
to a discharge review. Should a review be requested and the determination concurs that the discharge
notice is appropriate; the determination is valid until noon the day after the patient receives the IPRO/IPRA
notice. The hospital may discharge the patient to an Residential Healthcare Facility (RHCF), even if the
RHCF is not the patient’s preferred facility. Should an RHCF no longer have a bed available, due to the
time involved to complete a discharge review, the patient may remain in the hospital awaiting another
available bed. A new discharge notice ensuring the patient’s right to a subsequent review must be issued
when another RHCF bed becomes available.
For a Medicaid recipient, the hospital will continue to be reimbursed at the Alternate Level of Care rate
during the discharge review process. However, should a patient refuse the available bed, after the
determination upholding the notice, then the patient may be financially liable pursuant to the Office of
Medicaid Management.
For Medicare patients whose benefits have been terminated in accordance with the Quality Improvement
Organizations (QIO) requirements and who subsequently remain in the hospital on Alternate Level of
Care as self-pay, Medicaid or other third party, the discharge review requirements applicable to the new
payor become effective. These patients are to be given the right to a review by the IPRA in accordance
with the policies in the accordance with the regulation in 405.9.
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October 16, 2005
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PROCEDURES
ISSUANCE OF DISCHARGE NOTICES
Procedure when hospitalized patient requests a review and the hospital and the physician agree with
the proposed patient discharge plan and discharge notice:
1. Please be advised that hospitals are required to provide patients the Discharge Notice prior to noon the
day before discharge. In those instances where a notice is issued on the actual day of discharge and
such notice is provided by noon, the patient must be advised that he/she has until noon of the following
day to file an appeal. It should be noted that the patient always has the right to be discharged the same
day if the patient decides not to exercise his/her right to an appeal.
2. When completing the Discharge Notice the date at the top of the form, “date of notice”, should be the
day the patient is given the notice, the date in the first paragraph of the notice should be the day the
patient is ready for discharge and the date in the fourth paragraph, “if you would like a review” should be
noon the next day. (See example letter completed when patient given notice on expected day of
discharge.)
3. If the patient disagrees with the discharge plan and/or the discharge notice, the patient notifies
IPRO/IPRA (or a hospital representative who is responsible in turn for notifying IPRO/IPRA to initiate an
appeal). Notification to IPRO is made by telephone to 1-800-648-IPRO (4776). In accordance with the
DOH NYCRR Title 10 405.9 Admission/ Discharge standards, the patient has until noon of the next day
after the patient received the notice to request a review. IPRO is available for Discharge Reviews
Monday through Friday, 8:30 a.m. – 4:30 p.m. (Note: If IPRO is not The Independent Review Agent for
the patient the hospital must assist the patient in contacting the appropriate review agent. See updated
IPRA attached to this documented.)
4. a) Within one (1) hour of IPRO’s receipt of a request for a Discharge Review, IPRO will notify the
hospital Utilization Review Department or the hospital designated staff person/department by telephone
that a request for an appeal has been made. The hospital will also be notified at this time that they may
confer and offer any additional information to IPRO prior to completion of the review. It shall be the
hospital’s responsibility to notify the attending physician of both the appeal and the physician’s right to
confer and offer additional information to IPRO.
b) In notifying the hospital of the patient’s request for appeal, IPRO will provide the following information
to the hospital designated staff person/department: Patient name, date of birth; patient’s room number
and/or telephone extension; date/time of call; name of caller (if other than patient); Social Security
number if available and date of admission.
c) In order to conduct the review required, IPRO shall request a copy of the medical record, discharge
plan, discharge notice, and appropriate discharge plan/instructions and social service documentation. If
the length of stay exceeds ten (10) days, the hospital may either send the patient’s entire medical
documentation or at a minimum a copy of the following:
-
the admission history and physical examination;
the admission notes;
the initial nursing assessment;
any operative reports. Should the transcription of such reports not be completed, the progress
note summarizing the procedure shall be provided;
pathology reports, if appropriate;
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 4 of 15
-
-
all notes from the last 10 days the patient has been in the hospital. This shall include progress
notes, order sheets, nurses’ notes, medication reports, laboratory and radiology reports,
consultation reports, and discharge plan/instructions or social services notes; and
discharge notice and discharge plan
IPRO may request additional documentation, as it deems necessary to make a determination. If IPRO
is already in possession of the medical record, only additional documentation, not previously sent to
IPRO will be requested.
If a hospital representative contacts IPRO on behalf of a patient to request a discharge review, the
information listed in 4c will be provided to IPRO by the hospital at the time of the telephone contact.
5. When a patient contacts IPRO to request a discharge review, the IPRO staff member will solicit the
patient’s views regarding the reason(s) he/she feels the discharge plan/instruction and/or discharge
notice are inappropriate. If a hospital representative calls IPRO on behalf of the patient, IPRO will
request the hospital to assist IPRO in contacting the patient to obtain the patient’s reason(s) for
requesting the review. At the time of the initial request for review, the patient will be informed that IPRO
will be requesting his/her medical record from the hospital and explain the timeframes involved with the
review process.
Should a patient, prior to IPRO’s rendering a determination, withdraw his/her request for review, IPRO
will notify the hospital of the patient’s request. Such a request will complete the review process and no
further action will be taken.
6. All discharge review requests will be logged by IPRO, noting the date, time and identifying case
information at the time of the initial contact.
7. When IPRO notifies the hospital of the patient’s appeal, (or the hospital representative notifies IPRO
when filing an appeal on the patient’s behalf) the hospital has until the close of business on the day
following the day the patient received the discharge notice to deliver the medical record to IPRO. When
supplying the medical documentation, the hospital must also provide verification of the patient’s current
room number, telephone extension, and contact information for the attending physician.
8. Should a hospital wish to provide IPRO with the medical documentation by overnight or personal
delivery service, and the documentation is received by 11:00 a.m. the next day, IPRO will complete the
review by close of business of that day. IPRO cannot accept full or large partial charts by facsimile
machine.
9. IPRO’s review of the case will include:
Assignment of the case to a nurse reviewer and a physician. An IPRO physician will make all final
determinations. If the case has been previously reviewed by IPRO, (e.g. patient may have
successfully appealed in the past or hospital may have unsuccessfully appealed the discharge),
the review will be assigned to a physician who has not previously been involved in any review of
the case.
Discussion of the case with the patient or patient’s representative prior to rendering a final
determination.
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October 16, 2005
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IPRO availability to discuss the case with a hospital representative and/or the attending physician.
As detailed in # 4 c above, the hospital and/or the attending physician may clarify the discharge
plan and provide additional information prior to completion of the review.
Assessment of the patient’s medical necessity and need for continued inpatient care; the
appropriateness of the discharge plan and the discharge notice; and the availability of required
continuing health care services.
Assessment of the hospital/patient actions within regulatory timeframes in requesting review and
providing notices and medical documentation.
10. If IPRO’s determination is in favor of the patient, then the patient shall remain in the hospital and
continued stay in a hospital shall be deemed necessary and appropriate for the patient.
The hospital must issue another discharge notice when discharge is again deemed appropriate by the
hospital. The patient is eligible to request a subsequent discharge review each time a discharge notice
is tendered.
11. IPRO will notify the hospital by telephone of its review determination on the day of or within one (1) day
of receipt of the medical documentation, and provide written notification either by facsimile or overnight
mail. It shall be the hospital’s responsibility to provide the notice to the patient and a copy to the
attending physician informing them of the results of the review. IPRO also will include, for the hospital’s
use, the rationale for the determination when a patient’s request is upheld.
12. IPRO will maintain a log to record the review determinations including the date completed and time the
hospital was notified.
Procedure when a discharged patient (or representative) requests a review after discharge:
1. For both written and telephone requests IPRO will validate that the request was made within the
mandated timeframe, i.e. no later than thirty (30) days after receipt of a discharge notice or seven (7)
days after receipt of a complete bill for all inpatient services rendered, whichever is later. This may
require contacting the hospital to verify the date and time of the discharge notice and the complete bill.
For telephone requests, IPRO will solicit the name of caller (if other than patient) relationship (if other
than the patient), the patient’s name, date of birth, social security number, date of admission, hospital
name, patient or representative telephone number, patient’s address, date of discharge, date of
discharge notice, insurance company/payor source and insurance/payor identification number and
rationale for requesting the review.
2. If the timeframe for a request for a review has lapsed, the patient or the patient’s representative and the
hospital are notified in writing that the request was not within the mandated timeframes and that no
discharge review will occur. If the patient can provide documentation showing the request was timely, a
discharge review is performed.
3. When it is determined that the request is timely, a request for the medical record, discharge plan,
discharge notice, discharge planning and social service documentation and the bill is made to the
hospital.
The hospital is informed at the time of the request that they may confer and offer any additional
information to IPRO prior to conclusion of the review. It shall be the hospital’s responsibility to inform the
attending physician of the review request, and, of the physician’s right to confer and offer any additional
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
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information to IPRO prior to the conclusion of the review. The hospital shall be requested to provide
IPRO with the documentation within one (1) day.
4. IPRO’s review of the case includes:
Assignment of the case to a nurse reviewer and a physician consultant. An IPRO physician will
make all final determinations. If the case has been previously reviewed by IPRO, (i.e. patient may
have successfully appealed in the past or hospital may have unsuccessfully appealed the
discharge), the review will be assigned to a physician who has not been involved in any prior review
of the case.
Discussion of the case with the patient prior to rendering a determination, if the written request for
review does not describe the rational for requesting such a review.
Assessment of the appropriateness of the discharge/discharge plan and discharge notice to the
patient, and the availability of the planned continuing health care services.
5. IPRO will complete its review and provide written notice within three (3) working days of receipt of the
required medical documentation from the hospital. The written review results will be provided to the
hospital and the patient. The hospital will be required to notify the attending physician of IPRO’s
determination.
Procedure when the hospital requests a discharge appeal and the attending physician disagrees with
the proposed discharge, discharge plan or discharge notice:
1. The hospital may contact IPRO by telephone regarding the proposed discharge. At the time of the call
the hospital should provide the patient’s name, social security number, attending physician contact
information, date of admission, patient contact information (including the telephone number), date of
proposed discharge, in addition to a copy of the medical record, discharge plan and social service notes.
IPRO will advise the hospital that prior to the conclusion of the review the attending physician and/or
patient shall have the opportunity to confer and provide any additional information regarding the care of
the patient.
2. The hospital shall not provide any discharge notice to a patient prior to IPRO completing a discharge
review and providing written notice.
3. The process of reviewing discharge appeal cases when a hospital requests the review will follow the
same steps as when a patient requests the review.
4. Within one (1) day of receipt of the medical documentation, IPRO will notify the hospital, via telephone,
of the results of the review and provide written notification either by facsimile or overnight mail. It shall
be the hospital’s responsibility to provide the notice to the attending physician informing him/her of the
results of the review.
5. If the IPRO determination is made in favor of the hospital, then the hospital may issue the discharge
notice entitled “Continued Stay Discharge Notice Attending Disagrees/Review Agent Agrees” to the
patient.
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October 16, 2005
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6. If IPRO makes a determination in favor of the attending physician, no notice shall be given to the patient
and the patient’s continued stay in the hospital shall be deemed necessary and appropriate for the
patient for purposes of payment for such continued stay.
7. When the patient receives the discharge notice the patient may contact IPRO for a discharge review
which will be assigned to a physician who did not participate in the original hospital requested review.
The process would then follow the steps described under “Hospital and Physician Agree” section
described earlier.
A sample copy of the each discharge notice approved by the New York State Hospital Review and Planning
Council is attached as well as a sample completed Discharge Form highlighting the information that needs to be
completed.
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 8 of 15
The following form shall be used for patients covered under the case payment system.
DISCHARGE NOTICE
Date: ____/____/____
READ THIS LETTER CAREFULLY. IT CONCERNS YOUR PRIVATE INSURANCE BENEFITS OR
MEDICAID BENEFITS OR IF YOU ARE UNINSURED
PATIENT NAME: ______________________________ PRIMARY PAYOR AT DISCHARGE:_____________
ATT. PHYS:____________________MR #__________ADM DATE:_________________________________
Dear Patient:
Your doctor and the hospital have determined that you no longer require care in the hospital and will be
ready for discharge on:
______________________
Day of the Week
____/____/____
Date
IF YOU AGREE with this decision, you will be discharged. Be sure you have already received your
written discharge plan, which describes the arrangements for any future health care you may need when you
leave the hospital.
IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge
plan will not meet your health care needs, you or your representative may request a review. Contact the review
agent indicated on the reverse side of this letter if you would like a review of the discharge decision.
IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of _____(insert day
and date)___ call the telephone number checked off on the reverse side of this page.
IF YOU CANNOT REQUEST THE REVIEW YOURSELF and you do not have a family member or
friend to help you; you may ask the hospital representative at extension _____, who will request the review for
you.
IF YOU REQUEST A REVIEW, the following will happen:
1. The review agent will ask you or your representative why you or your representative think you need
to stay in the hospital and also will ask your name, admission date and telephone number where
you or your representative can be reached.
2. After speaking with you or your representative and your doctor and after reviewing your medical
record, the review agent will make a decision, which will be given to you in writing.
3. While this review is being conducted, you will not have to pay for any additional hospital days until
you have received the review agent’s decision.
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 9 of 15
IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION, you will be financially
responsible for your continued stay after noon of the day after you or your representative has been notified of
the review agent’s decision.
IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO BE IN THE HOSPITAL: for
MEDICAID patients, Medicaid benefits will continue to cover your stay; for private health insurance patients,
coverage for your continued stay is limited to the scope of your private health insurance policy.
NOTE:
If you miss the noon deadline mentioned on the first page of this notice, you may still request a
review. However, if the review agent disagrees with you, you will be financially responsible for
the days of care beginning with the proposed discharge date.
If you would like a review of your hospital stay after you have been discharged, you may request a review by the
review agent within thirty (30) days of the receipt of this notice or seven days after receipt of a complete bill from
the hospital, whichever is later, by writing to the review agent.
I have received this notice on behalf of myself as the patient or as the representative of the patient:
_______________________________________
Signature
_______________________________________
Relationship
_____/_____/_____
_________________
Date
Time
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 10 of 15
Sample Completed Discharge Form:
DISCHARGE NOTICE
Date: 04 / 01 / 06
Date patient
given the
notice.
READ THIS LETTER CAREFULLY. IT CONCERNS YOUR PRIVATE INSURANCE BENEFITS OR
MEDICAID BENEFITS OR IF YOU ARE UNINSURED
PATIENT NAME: ______________________________ PRIMARY PAYOR AT DISCHARGE:_____________
ATT. PHYS:____________________MR #__________ADM DATE:_________________________________
Dear Patient:
Your doctor and the hospital have determined that you no longer require care in the hospital and will be
ready for discharge on:
Tuesday
Day of the Week
04 / 02 / 06
Date
Date ready
for Discharge
IF YOU AGREE with this decision, you will be discharged. Be sure you have already received your
written discharge plan, which describes the arrangements for any future health care you may need when you
leave the hospital.
IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge
plan will not meet your health care needs, you or your representative may request a review. Contact the review
agent indicated on the reverse side of this letter if you would like a review of the discharge decision.
Next day
by noon.
IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of Tuesday
04 / 02 / 06 call the telephone number checked off on the reverse side of this page.
IF YOU CANNOT REQUEST THE REVIEW YOURSELF and you do not have a family member or
friend to help you; you may ask the hospital representative at extension _____, who will request the review for
you.
IF YOU REQUEST A REVIEW, the following will happen:
1.
The review agent will ask you or your representative why you or your representative think you need
to stay in the hospital and also will ask your name, admission date and telephone number where
you or your representative can be reached.
2.
After speaking with you or your representative and your doctor and after reviewing your medical
record, the review agent will make a decision, which will be given to you in writing.
3.
While this review is being conducted, you will not have to pay for any additional hospital days until
you have received the review agent’s decision.
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 11 of 15
IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION, you will be financially
responsible for your continued stay after noon of the day after you or your representative has been notified of
the review agent’s decision.
IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO BE IN THE HOSPITAL: for
MEDICAID patients, Medicaid benefits will continue to cover your stay; for private health insurance patients,
coverage for your continued stay is limited to the scope of your private health insurance policy.
NOTE:
If you miss the noon deadline mentioned on the first page of this notice, you may still request a
review. However, if the review agent disagrees with you, you will be financially responsible for
the days of care beginning with the proposed discharge date.
If you would like a review of your hospital stay after you have been discharged, you may request a review by the
review agent within thirty (30) days of the receipt of this notice or seven days after receipt of a complete bill from
the hospital, whichever is later, by writing to the review agent.
I have received this notice on behalf of myself as the patient or as the representative of the patient:
_______________________________________
Signature
_______________________________________
Relationship
_____/_____/_____
_________________
Date
Time
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 12 of 15
The following form shall be used for patients covered under the per diem reimbursement system.
Date: ____/____/____
READ THIS LETTER CAREFULLY. IT CONCERNS YOUR PRIVATE INSURANCE BENEFITS OR
MEDICAID BENEFITS OR IF YOU ARE UNINSURED
PATIENT NAME: ______________________________ PRIMARY PAYOR AT DISCHARGE:____________
ATT. PHYS_____________________MR#__________ADM. Date_________________________________
Dear Patient:
Your doctor and the hospital have determined that you no longer require care in the hospital and will be ready
for discharge on:
______________________
Day of the Week
____/____/____
Date
IF YOU AGREE with this decision, you will be discharged. Be sure you have already received your
written discharge plan, which describes the arrangements for any future health care you may need when you
leave the hospital
IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge
plan will not meet your health care needs, you or your representative may request a review of the
discharge decision by contacting your review agent indicated on the reverse side of this page.
IMPORTANT NOTICE ABOUT THE PAYMENT FOR YOUR CARE
o
o
If your hospital care is covered by private health insurance, you may be charged directly while you
remain in the hospital while the discharge review is being conducted. Whether you have to pay during
this period will depend on your private health insurance benefits and if the review agent agrees with you
that you need to stay in the hospital.
If your hospital care is covered under the Medicaid program, Medicaid will pay for the days you remain
in the hospital while the discharge review is being conducted.
IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of _____(insert day
and date)___ call the telephone number checked off on the reverse side of this page.
IF YOU CANNOT REQUEST THE REVIEW YOURSELF and you do not have a family member or
friend to help you; you may ask the hospital representative at extension _____, who will request the review for
you.
IF YOU REQUEST A REVIEW, the following will happen:
IF YOU CANNOT REQUEST THE REVIEW YOURSELF and you do not have a family member or friend to
help you; you may ask the hospital representative at extension _____, who will request the review for you.
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October 16, 2005
Page 13 of 15
IF YOU REQUEST A REVIEW, the following will happen:
1. The review agent will ask you or your representative why you or your representative think you need
to stay in the hospital and also will ask your name, admission date and telephone number where
you or your representative can be reached.
2. After speaking with you or your representative and your doctor and after reviewing your medical
record, the review agent will make a decision which will be given to you in writing.
IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION, you will be financially
responsible for your continued stay after noon of the day after you or your representative has been notified of
the review agent’s decision.
IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO BE IN THE HOSPITAL: for
MEDICAID patients, Medicaid benefits will continue to cover your stay; for private health insurance patients,
coverage for your continued stay is limited to the scope of your private health insurance policy.
NOTE:
If you miss the noon deadline mentioned on the first page of this notice, you may still request a
review. However, if the review agent disagrees with you, you will be financially responsible for
the days of care beginning with the proposed discharge date.
If you would like a review of your hospital stay after you have been discharged, you may request a review by the
review agent within thirty (30) days of the receipt of this notice or seven days after receipt of a complete bill from
the hospital, whichever is later, by writing to the review agent.
I have received this notice on behalf of myself as the patient or as the representative of the patient:
_______________________________________
Signature
_______________________________________
Relationship
_____/_____/_____
_________________
Date
Time
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Medicaid Administrative Memorandum #2006-07
October 16, 2005
Page 14 of 15
Notice that inpatient hospital services is no longer medically necessary a hospital shall utilize
the following notice:
CONTINUED STAY DISCHARGE NOTICE
(ATTENDING PHYSICIAN DISAGREES/REVIEW AGENT AGREES)
READ THIS LETTER CAREFULLY. IT CONCERNS YOUR INSURANCE BENEFITS OR
MEDICAID BENEFITS
Date: ____/____/____
PATIENT NAME:____________________________PRIMARY PAYOR:___________________________
ADDRESS____________________________________________________________________________
ATT. PHYS:___________________________MR NO:__________________ADM. DATE: ____/____/____
Dear Patient:
After careful review of your medical record and consideration of your own views regarding medical condition, the
(name of review agent) (the review agent approved by the Department of Health) has agreed with the hospital
that you no longer require care in the hospital because you are ready for discharge.
IF YOU AGREE with this decision, you should discuss with your doctor the arrangements for any further health
care you may need. This means if you have health insurance benefits or Medicaid benefits, these benefits will
no longer pay for any additional hospital days as of:
_____________________
Day of the Week
____/____/____
Date
IF YOU DO NOT AGREE THAT YOU ARE READY FOR DISCHARGE, IMMEDIATELY AFTER RECEIPT OF
TIS NOTICE YOU OR YOUR REPRESENTATIVE MAY CALL THE (name of review agent) AT (phone no.) TO
REQUEST AN IMMEDIATE REVIEW OF YOUR MEDICAL RECORD.
If you cannot request the reconsideration yourself and you do not have a representative to help you, you may
notify the hospital representative at extension ________ to request the reconsideration for you. In either case,
the individual review agent approved by the Department of Health will request your name, admission date, and
telephone number where you or your representative can be reached. If the individual review agent approved by
the Department of Health did not ask your views before, it must do so now.
IF YOU REQUEST A REVIEW, the following will happen:
(1) You or your representative will be informed in writing of the results of the review.
(2) IF THE REVIEW AGENT AGREES WITH THE HOSPITALS’S DECISION that you are ready for discharge
or that your condition could be safely treated in another setting and you have health insurance benefits or
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October 16, 2005
Page 15 of 15
Medicaid benefits, your health insurance benefits or Medicaid benefits will PAY FOR YOUR STAY ONLY
UNTIL NOON OF THE NEXT DAY AFTER YOU OR YOUR REPRESENTATIVE HAVE BEEN NOTIFIED.
(3) If the review agent determines that you still need to be in the hospital, for purposes of payments under
health insurance or Medicaid benefits, your continued stay will be considered necessary and appropriate.
IN EITHER CASE (2 OR 3), YOU WILL NOT HAVE TO PAY FOR ANY ADDITIONAL HOSPITAL DAYS
UNTIL YOU HAVE BEEN NOTIFIED OF THE REVIEW AGENT DETERMINATION.
NOTE: If you miss the noon deadline mentioned on the reverse side of this notice, you may still request a
review during your hospital stay. However, if the review agent rules against you, you will be financially
responsible starting on the date you receive the notice. Of course, if the review agent determination is in your
favor, you are not liable for payment for the extra days.
If you would like a review of your hospital stay after you have been discharged, you may request an individual
review agent review within 30 days of receipt of this notice or seven days after receipt of a complete bill from the
hospital, whichever is later, by writing to the review agent.
(REVIEW AGENT NAME/ADDRESS)
___________________________________________________________________________
____________________________
(Hospital Representative Signature
____/____/____
(Date)
___________
(Time)
If your hospital stay is not covered under the per case payment system, you may still request a discharge
review. However, you will continue to be charged for hospital services during the review process.
IF YOU HAVE ANY DIFFICULTY UNDERSTANDING THIS NOTICE OR IF YOU NEED MORE
INFORMATION, YOU MAY CALL THE REVIEW AGENT DIRECTLY AT:
________________________________
(Telephone No.)
I have received this notice on behalf of myself as the patient or as a representative of the patient to whom it is
addressed:
__________________________
Signature
__________________________
Relationship
cc: Attending Physician
Hospital Billing Office
____/____/____
Date
__________
Time