• IntegraNet will forward the appeal to an Independent Review Organization (IRO) contracted with the federal government. The IRO will review the appeal and decide:
• Within 72 hours if expedited
• Within 30 days* if the appeal is related to authorization for health care
• Within 60 days* if the appeal involves reimbursement for care
• Prescription drug appeals are not forwarded to the IRO by IntegraNet but may be requested by the member or representative; information will be provided on this process during the IntegraNet member appeals process
• If the IRO issues an adverse decision (not in the member's favor) and the amount at issue meets a specified dollar threshold, the member may appeal to an Administrative Law Judge (ALJ)
• If the member is not satisfied with the ALJ’s decision, the member may request review by the Medicare Appeals Council. If the Medicare Appeals Council refuses to hear the case or issues an adverse decision, the member may be able to appeal to a federal court

*Some plans may have different turnaround times due to state requirements.

Hospital discharge appeals and QIO review process
Hospital discharges are subject to the expedited member appeal process. CMS has determined that Medicare Advantage members wishing to appeal an inpatient hospital discharge must request an immediate review from the appropriate Quality Improvement Organization (QIO) authorized by Medicare to review the hospital care provided to Medicare patients.

When a Medicare Advantage member does not agree with the physician’s decision of discharge from the inpatient hospital setting, then the member must request an immediate review by the QIO. The member or their authorized representative, attorney, or court-appointed guardian must contact the QIO by telephone or in writing. This request must be made no later than noon of the first working day after the member receives the Notice of Discharge and Medicare Appeal Rights. The QIO will decide within one full working day after it receives the member’s request, the appropriate medical records, and any other information it needs to make a decision. While the member remains in the hospital, IntegraNet continues to be responsible for paying the costs of the stay until noon of the calendar day following the day the QIO notifies the member of its official Medicare coverage decision.

If the QIO agrees with the physician’s discharge decision, the member will be responsible for paying the cost of the hospital stay beginning at noon of the calendar day following the day the QIO provides notification of its decision. If the QIO disagrees with the physician’s discharge decision, the member is not responsible for paying the cost of additional hospital days.

If a Medicare Advantage member misses the deadline to file for an immediate QIO review, then he/she may request an expedited appeal. In this case, the member does not have automatic financial protection during the expedited appeal and may be financially liable for paying for the cost of the additional hospital days if the original decision to discharge is upheld upon appeal.