42 C.F.R. § 422.620 How enrollees of MA organizations must be notified of noncovered inpatient hospital care.
Title 42 - Public Health
(a) Enrollee's entitlement. (1) Where an MA organization has authorized coverage of the inpatient admission of an enrollee, either directly or by delegation (or the admission constitutes emergency or urgently needed care, as described in §§422.2 and 422.113), the MA organization (or hospital that has been delegated the authority to make the discharge decision) must provide a written notice of noncoverage when— (i) The beneficiary disagrees with the discharge decision; or (ii) The MA organization (or the hospital that has been delegated the authority to make the discharge decision) is not discharging the individual but no longer intends to continue coverage of the inpatient stay. (2) An enrollee is entitled to coverage until at least noon of the day after such notice is provided. If QIO review is requested under §422.622, coverage is extended as provided in that section. (b) Physician concurrence required. Before discharging an individual or changing the level of care in an inpatient hospital setting, the MA organization must obtain the concurrence of the physician who is responsible for the enrollee's inpatient care. (c) Notice to the enrollee. When applicable, the written notice of non-coverage must be issued no later than the day before hospital coverage ends. The written notice must include the following elements: (1) The reason why inpatient hospital care is no longer needed or covered; (2) The effective date and time of the enrollee's liability for continued inpatient care; (3) The enrollee's appeal rights; (4) If applicable, the new lower level of care being covered in the hospital setting; and (5) Any additional information specified by CMS. [68 FR 16667, Apr. 4, 2003, as amended at 70 FR 4740, Jan. 28, 2005] Effective Date Note: At 68 FR 20349, Apr. 4, 2003, §422.620 was revised. This section contains information collection and recordkeeping requirements and will not become effective until approval has been given by the Office of Management and Budget
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart M—Grievances, Organization Determinations and Appeals
§ 422.620 How enrollees of MA organizations must be notified of noncovered inpatient hospital care.
