Track Change - Instruction Detailed Notice of Discharge

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Form Instructions for the Detailed Notice of Discharge

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(DND) CMS-10066

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A hospital or Medicare health plan must deliver a completed copy of the Detailed
Notice of Discharge (DND)is notice to beneficiaries/enrollees upon notificationice from
the Quality Improvement Organization (QIO) that the beneficiary/enrollee has
appealed a discharge from an inpatient hospital stay. The DND must be provided no
later than noon of the day after the QIO’s notification.

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Patient name: Fill in the beneficiary’s/enrollee’s first and last name.

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Patient number: The patient number may be a unique medical record or other
provider-issued identification number. It may not be the Social Security Number, HICN
or any other Medicare-issued number for the beneficiary’s such as the MBI (Medicare
Beneficiary Identifier).

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Hospital or health plan name: The name of the hospital or Medicare health plan that
delivers the notice must appear here.

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Hospital or health plan address: The address of the hospital or Medicare health plan
that delivers the notice must appear here.

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Hospital or health plan telephone number: The telephone number of the hospital or
Medicare health plan that delivers the notice must appear here.

Date: Fill in the date the notice is delivered by the hospital or plan.
Patient Name: Fill in the beneficiary’s/enrollee’s first and last name.
Patient number: The Patient number may be a unique medical record or other
provider-issued identification number. It may not be the Social Security Number, HICN
or any other Medicare number issued to the beneficiary such as the MBI (Medicare
Beneficiary Identifier).
Bullet # 1
The facts used to make this decision: Fill in the patient specific
information that describes the current functioning and progress of the
beneficiary/enrollee with respect to the services being provided. Use full sentences, in
plain language.

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Form CMS 10065• E x p. xx/xx/2xxxx• OMB approval 0938-1019

Date: Fill in the date the notice is delivered by the hospital or plan.
Heading: Insert contact information here: The name, address and telephone number
of the hospital or Medicare health plan that delivers the notice must appear above the
title of the form. The entity’s registered logo is not required, but may be used.

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Bullet # 2
The detailed explanation of why the services are no longer covered. Fill in
the detailed and beneficiary specific reasons why the hospital stay is no longer
reasonable or necessary for the beneficiary/enrollee, or is no longer covered according
to the Medicare guidelines. Describe how the beneficiary/enrollee condition does not
meet these guidelines. Use full sentences, in plain language.
Bullet # 3 (Medicare health plans only) The plan policy, provision, or rationale used in
the decision if the notice is delivered to a health plan enrollee: Fill in the reasons
services are no longer covered according to the plan’s policy guidelines, if applicable.
Describe how the enrollee does not meet these guidelines. If the plan relied exclusively
on Medicare coverage guidelines, please explain that here. Use full sentences, in plain
language.

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If you would like a copy of the policy section: If the hospital or Medicare health plan
has not provided the Medicare guidelines or policy used to decide the discharge date,
inform the beneficiary/enrollee on how and where to obtain the policy. Provide the
hospital/plan name and toll-free number for beneficiaries/enrollees to obtain a copy of
the relevant documents sent to the QIO.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1019. The time required to complete this information collection is estimated to average 60 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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