CMS SOM App. A, Tag A-0120

[The hospital must establish a process for prompt resolution of patient grievances and must

inform each patient whom to contact to file a grievance. The hospital’s governing body must

approve and be responsible for the effective operation of the grievance process, and must review

and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.]

The grievance process must include a mechanism for timely referral of patient concerns regarding

quality of care or premature discharge to the appropriate Utilization and Quality Control Quality

Improvement Organization. At a minimum:

Interpretive Guidelines §482.13(a)(2)

Quality Improvement Organizations (QIOs) are CMS contractors charged with reviewing the

appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. The QIOs

are also tasked with reviewing utilization decisions. Part of this duty includes reviewing discontinuation

of stay determinations based upon a beneficiary’s request. The regulations state the functions of the

QIOs in order to make Medicare beneficiaries aware of the fact that if they have a complaint regarding

quality of care, disagree with a coverage decision, or they wish to appeal a premature discharge, they

may contact the QIO to lodge a complaint. The hospital is required to have procedures for referring

Medicare beneficiary concerns to the QIOs; additionally, CMS expects coordination between the

grievance process and existing grievance referral procedures so that beneficiary complaints are handled

timely and referred to the QIO at the beneficiary’s request.

This regulation requires coordination between the hospital’s existing mechanisms for utilization review

notice and referral to QIOs for Medicare beneficiary concerns (See 42 CFR Part 489.27). This

requirement does not mandate that the hospital automatically refer each Medicare beneficiary’s

grievance to the QIO; however, the hospital must inform all beneficiaries of this right, and comply with

his or her request if the beneficiary asks for QIO review.

Medicare patients have the right to appeal a premature discharge (see Interpretive Guidelines for 42

CFR 482.13(a)). Pursuant to 42 CFR 412.42(c)(3), a hospital must provide a hospital-issued notice of

non-coverage (HINN) to any fee-for-service beneficiary that expresses dissatisfaction with an

impending hospital discharge. Medicare Advantage (MA) organizations are required to provide

enrollees with a notice of non-coverage, known as the Notice of Discharge and Medicare Appeal Rights

(NODMAR), only when a beneficiary disagrees with the discharge decision or when the MA

organization (or hospital, if the MA organization has delegated to it the authority to make the discharge

decision) is not discharging the enrollee, but no longer intends to cover the inpatient stay.

Survey Procedures §482.13(a)(2)

• Review patient discharge materials. Is the hospital in compliance with 42 CFR §489.27?

• Does the hospital grievance process include a mechanism for timely referral of Medicare patient

concerns to the QIO? What time frames are established?

• Interview Medicare patients. Are they aware of their right to appeal premature discharge?