CALIFORNIA - Pacificare Health Systems

PART B
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Your request to expedite an Appeal
decision is accepted, PacifiCare makes a
decision in seventy-two (72) hours and
notifies you that that the care will not be
arranged or continued and the case will
be sent to the Independent Review Entity
for determination within twenty-four (24)
hours.
Your request to expedite an Appeal
decision is not accepted, and PacifiCare
informs you that your request will be
handled under the standard Appeal
process.
Your request to expedite an Appeal
decision cannot be made in seventytwo
(72) hours, and PacifiCare informs
you that PacifiCare will need up to an
additional fourteen (14) calendar days to
process your request.
If you have questions regarding these rights,
please call Customer Service.
Information You Should Receive During
Your Hospital Stay
When you are admitted to the Hospital,
someone at the Hospital should give you a
notice called the Important Message from
Medicare. This notice explains your rights
under the law. When a doctor decides that
you are ready to leave the Hospital (to “be
discharged”), and if you believe you should
not be discharged yet, you should be given a
copy of another notice that includes specific
information about your Hospital discharge.
This other notice is called the Notice of
Discharge and Medical Appeal Rights. It will
tell you:
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Section 9 – Organization Determination,
Appeals and Grievance Procedures
Why you are being discharged.
The date that we will stop covering your
Hospital Stay (stop paying our share of
your Hospital costs).
What you can do if you think you are
being discharged too soon.
Who to contact for help.
As a Member, you should receive this
information about your discharge before
you leave the Hospital. You (or someone you
authorize) may be asked to sign and date
this document, to show that you received
the notice. Signing the notice does not mean
that you agree that you are ready to leave the
Hospital – it only means that you received the
notice. If you do not receive the notice after
you have told the Hospital that you think you
are being discharged too soon, ask for the
Notice of Discharge and Medicare Appeal
Rights immediately.
Quality Improvement Review
If you are in the Hospital and you think that
you are being discharged too soon, you have
the right by law to ask for a review of your
discharge date. As explained in the Notice of
Discharge and Medicare Appeal Rights, if you
act quickly, you can ask an outside agency
called the Quality Improvement Organization
(QIO) to review whether your discharge is
medically appropriate.
The QIO is a group of doctors and other
health care experts paid by the federal
government to check on and help improve
the care given to Medicare patients. They are
not part of PacifiCare or your Hospital. There
is one QIO in each state. QIOs have different
names, depending on which state they are in.
The phone number and address of the QIO
for your area is:
Lumetra
CitiCorp Center
One Sansome Street, Suite 600
San Francisco, CA 94104-4405
1-415-677-2000
The doctors and other health experts in
the QIO review certain types of complaints
made by Medicare patients. These include
complaints about quality of care and complaints
from Medicare patients who think the coverage
for their Hospital Stay is ending too soon.
Getting a QIO Review of Your Hospital
Discharge
If you want to have your discharge reviewed,
you must act quickly to contact the QIO. The
Notice of Discharge and Medicare Appeal