CALIFORNIA - Pacificare Health Systems

Rights gives the name and telephone number
of your QIO and tells you what you must do.
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You must ask the QIO for an expedited
seventy-two (72)-hour review of whether
you are ready to leave the Hospital.
You must be sure that you have made
your request to the QIO no later than
noon on the first working day after you
are given written notice that you are
being discharged from the Hospital. This
deadline is very important. If you meet
this deadline, you are allowed to stay in
the Hospital past your discharge date
without paying for it yourself, while you
wait to get the decision from the QIO (see
below).
If the QIO reviews your discharge, it will first
look at your medical information. Then it will
give an opinion about whether it is medically
appropriate for you to be discharged on the
date that has been set for you. The QIO will
make this decision within one full working
day after it has received your request and all
of the medical information it needs to make a
decision.
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Section 9 – Organization Determination,
Appeals and Grievance Procedures
If the QIO decides that your discharge
date was medically appropriate, you will
not be responsible for paying the Hospital
charges until noon of the calendar day
after the QIO gives you its decision.
If the QIO agrees with you, then we will
continue to cover your Hospital Stay for as
long as Medically Necessary.
What if you do not ask the QIO for a
review by the deadline?
You may have to pay if you stay past your
discharge date.
If you do not ask the QIO by noon of the
next working day after you are given written
notice that you are being discharged from the
Hospital, and if you stay in the Hospital after
this date, you run the risk of having to pay for
the Hospital care you receive on and after this
date. However, you can Appeal any bills for
Hospital care you receive as described above.
Another Option: Asking for an
Expedited/72-Hour Review of Your
Discharge
If you do not ask the QIO to do an expedited
seventy-two (72)-hour review of your
discharge, you can ask us for an expedited
seventy-two (72)-hour review of your
discharge. This is described above. If you ask
us for an expedited seventy-two (72)-hour
review of your discharge and you stay in the
Hospital past your discharge date, you run
the risk of having to pay for the Hospital care
you receive past your discharge date. Whether
you have to pay or not depends on the
decision we make.
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If we decide, based on the expedited
seventy-two (72)-hour review, that you
need to stay in the Hospital, we will
continue to cover your Hospital care for as
long as Medically Necessary.
If we decide that you should not have
stayed in the Hospital beyond your
discharge date, then we will not cover any
Hospital care you received if you stayed in
the Hospital after the discharge date.
Termination of Services in Certain
Provider Settings (Skilled Nursing
Facility (SNF), Home Health Agency
(HHA), or Comprehensive Outpatient
Rehabilitation Facility (CORF))
When coverage for a Prior Authorized
course of treatment ends in a SNF, HHA, or
CORF, you should receive advance written
notification of the termination of services
that includes your Appeal rights and the
date on which coverage of the service ends.
This notice is called the Notice of Medicare
Non-Coverage. You must receive the notice
no later than two (2) days prior to the
termination (or at the time of admission if
your stay is expected to be less than two (2)
days). You (or someone you authorize) will
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 SNF, HHA, or CORF—it
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B