The Quality Improvement Organization conducts an independent review of your case. What happens during this review? • Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. • The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and our plan has given to them. • By noon of the day after the reviewers informed our plan of your appeal, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor, the hospital, and our plan think it is right (medically appropriate) for you to be discharged on that date.
The Quality Improvement Organization conducts an independent review of your case. What happens during this review? • Health professionals at the Quality Improvement Organization (we will call them “the reviewers” for short) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. • The review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them. • By the end of the day the reviewers informed our plan of your appeal, you will also get a written notice from the plan that gives our reasons for wanting to end the plan’s coverage for your services. Legal This notice explanation is called the Terms “Detailed Explanation of Non- Coverage.” Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes to your appeal? • If the reviewers say yes to your appeal, then our plan must keep providing your covered services for as long as it is medically necessary. • You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered services. What happens if the reviewers say no to your appeal? • If the reviewers say no to your appeal, then your coverage will end on the date we have told you. Our plan will stop paying its share of the costs of this care. • If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.
