Beginning July 1, 2007, all Medicare beneficiaries, including those in Aetna's Medicare Advantage Plans (HMO, PPO, PFFS), will be able to request immediate Quality Improvement Organization (QIO) review of an inpatient hospital discharge decision. Under this process, the QIO in the state in which services are provided will perform a third-party binding review of the inpatient hospital discharge decision.

For all "timely" Hospital Discharge Appeals, that is, those received before the Medicare member leaves the hospital, the following process will apply:

• When an Aetna Medicare Advantage member requests a Hospital Discharge Appeal, the QIO will contact hospital staff to obtain the member's medical records for review.
• The hospital may also be asked to communicate pertinent clinical criteria to a member of Aetna's Medicare Advantage team (based in Cranbury, NJ), for the purposes of completing the CMS-required Detailed Notice of Discharge.

We will process all "untimely" Hospital Discharge Appeal requests received, that is, those received after midnight on the day of discharge or after the Medicare member has left the hospital. These requests will be subject to the Medicare Expedited Grievance and Appeals Process.

For more information regarding the Hospital Discharge Appeal process, please contact us at 1-866-269-3692.

Please also see Hospital Discharge Appeal Notices on the Centers for Medicare & Medicaid Services (CMS) website.

You will find these specific documents on the CMS website listed above.

Important Message from Medicare (approved 5/2007) (3 pages)

Detailed Notice of Discharge (approved 5/2007)

CMS-4105 Manual Instructions

Resource 04-03-07 (FAQs) (8 pages)