Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges Detailed Notice of Discharge (CMS-10066)

Notice Instructions:

Detailed Notice of Discharge

(The Detailed Notice)

Upon notice from the Quality Improvement Organization (QIO) that a patient has requested an expedited review, hospitals and/or Medicare managed care plans (plans) must furnish a completed copy of this notice to patients in original Medicare or patients in Medicare Advantage or other Medicare managed care plans who are receiving inpatient hospital services. This notice must be provided as soon as possible, but no later than noon of the day after the hospital/plan are notified of the request by the QIO. This notice fulfills the requirements contained in Section 1869(c)(3)(C)(iii)(III) of the Social Security Act and implementing regulations.

This is a standardized notice. Hospitals/Plans may not deviate from the content of the form except where indicated. Please note that the OMB control number must be displayed on the upper right-hand corner of the notice.

Insert logo here: Hospitals/Plans may elect to place their logo in this space. The name, address, and telephone number of the hospital/plan must be immediately under the logo, if not incorporated into the logo. If no logo is used, the name and address and telephone number of the hospital/plan must appear above the title of the form.

Patient Name: Fill in the patient’s full name.

Patient ID number: Fill in the patient’s ID number. This should not be the social security or HICN number.

Attending Physician: Fill in the name of the patient’s attending physician.

Date Issued: Fill in the date the notice is delivered to the patient by the hospital/plan.

BLANK 1: “This notice gives you a detailed explanation of why your hospital and doctor, (and your managed care plan, if you belong to one) believe your hospital services should end on _________________________ based on Medicare coverage policies and medical judgment.” In the space provided, fill in planned date of discharge.

Bullet # 1: “The facts used to make this decision:” Fill in specific information that describes the current functioning and progress of this patient with respect to the services being provided. Use full sentences in plain English.

Bullet # 2: “Explanation of Medicare coverage policies that we used to determine that Medicare will no longer cover your hospital stay:” Fill in the detailed and specific reasons why services are no longer reasonable or necessary for this patient or are no longer covered according to Medicare coverage guidelines. Include facts that are specific to the patient’s individual case. Use full sentences in plain English.

Bullet # 3: “If applicable, Medicare managed care plan policies, provisions, or rationale used to make this decision:” If applicable, fill in the detailed and specific reasons why the plan considers services to be no longer covered for this patient. Use full sentences in plain English.

“If you would like a copy of the Medicare coverage policies or Medicare managed care policies used to make this decision . . . :” If the hospital/plan has not attached the Medicare policies and/or the Medicare managed care plan policies used to decide the discharge date, the hospital should supply a telephone number for patients to call to obtain copies of this information. The hospital/plan should also supply a telephone number for patients to call to get a copy of the relevant documents sent to the QIO.