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IF YOU THINK YOU ARE BEING ASKED TO LEAVE THE HOSPITAL TOO SOON
- Ask a hospital representative for a written notice of explanation immediately, if you have not already received one. This notice is called a "Notice of Non-Coverage." You must have this Notice of Non-Coverage if you wish to exercise your right to request a review by the PRO.
- The Notice of Non-Coverage will state either that your doctor or the PRO agrees with the hospital's decision that Medicare will no longer pay for your hospital care.
- If the hospital and your doctor agree, the PRO does not review your case before a Notice of Non-Coverage is issued. But the PRO will respond to your request for a review of your Notice of Non-Coverage and seek your opinion. You cannot be made to pay for your hospital care until the PRO makes its decision, if you request the review by noon of the first work day after you receive the Notice of Non-Coverage.
- If the hospital and your doctor disagree, the hospital may request the PRO to review your case. If it does not make such a request, the hospital is required to send you a notice to that effect. In this situation, the PRO must agree with the hospital or the hospital cannot issue a Notice of Non-Coverage. You may request that the PRO reconsider your case after you receive a Notice of Non-Coverage but because the PRO has already reviewed your case once, you may have to pay for at least one day of hospital care before the PRO completes this reconsideration.
IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY BEGINNING WITH THE THIRD DAY AFTER YOU RECEIVE THE NOTICE OF NON-COVERAGE. THE HOSPITAL, HOWEVER, CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF NON-COVERAGE.
HOW TO REQUEST A REVIEW OF THE NOTICE OF NON-COVERAGE
If the notice of Non-Coverage states that your physician agrees with the hospital's decision:
- You must take your request for review to the PRO by noon of the first work day after you receive the Notice of Non-Coverage by contacting the PRO by phone or in writing.
Chart Copy
- The PRO must ask for your views about your case before making its decision. The PRO will inform you by phone and in writing of its decision on the review.
- If the PRO agrees with the Notice of Non-Coverage, you may be billed for all costs of your stay beginning at noon of the day after you receive the PRO's decision.
- Thus, you will not be responsible for the cost of hospital care before you receive the PRO's decision.
If the Notice of Non-Coverage states that the PRO agrees with the hospital's decision:
- You should take your request for reconsideration to the PRO immediately upon receipt of the Notice of Non-Coverage by contacting the PRO by phone or in writing.
- The PRO can take up to three working days from receipt of your request to complete the review. The PRO will inform you in writing of its decision on the review.
- Because the PRO has already reviewed your case once, before the issuance of the Notice of Non-Coverage, the hospital is permitted to begin billing you for the cost of your stay beginning with the third calendar day after you receive your Notice of Non-Coverage even if the PRO has not completed its review.
- Thus, if the PRO continues to agree with the Notice of Non-Coverage, you may have to pay for at least one day of hospital care.
NOTE: The process described above is called "immediate review." If you miss the deadline for this immediate review while you are in the hospital, you may still request a review of Medicare's decision to no longer pay for your care at any point during your hospital stay or after you have left the hospital. The Notice of Non-Coverage will tell you how to request this review. |
