What is this appeals process?

When Medicare Says "Time's Up"

When your loved one is in a skilled nursing facility (SNF) for rehab after a stroke, surgery, or other medical event, Medicare or your insurance will eventually say coverage is ending. This often feels sudden and premature.

What is a QIO?

A Quality Improvement Organization (QIO) is an independent group that reviews Medicare appeals. Names like "Commence Health" or "Livanta" are QIOs. They're separate from your insurance company.

The Appeal Levels

Level 1 (Fast Appeal): Goes to the QIO. Usually decided within 1-2 days.
Level 2 (Reconsideration): If Level 1 is denied, this goes to an Independent Review Entity (IRE). Fresh review by different doctors.
Level 3 (ALJ Hearing): Administrative Law Judge. Much slower (90+ days).

Critical: Tight Deadlines!

You often have until noon the next day to file an appeal. Filing on time means your loved one can stay (with Medicare paying) during the review. This is called a "protected stay."

The "Maintenance Standard"

Important: Medicare coverage is NOT just for "improvement." Your loved one can qualify for continued coverage to maintain function or prevent deterioration. If they need skilled care to avoid getting worse, that counts.

What Reviewers Look For

Specific safety risks (falls, infections, skin breakdown)
Level of dependence (how many people needed for transfers?)
Evidence therapy is working (any progress?)
Why home isn't safe yet, even with family support

1. Patient Information

Patient's First Name

Your Relationship

Facility Name

Condition / Reason for Admission

What happened that led to the facility stay?

Admission Date

Proposed Discharge Date (if known)

2. What You Have Observed

Mobility Status

Can they walk? Stand? Bear weight?

Transfer Assistance Needed

How many people does it take to move them? Be specific about what you've seen.

Therapies Receiving

What therapy and how often?

Recent Progress

Any improvements you've noticed? Specific is better.

3. Safety Concerns

What Would Happen If Discharged Now?

What are you worried about?

Home Support Available

Who will be there? What's the plan?

What You Can't Do Alone

Be honest about limitations

4. Why Stay the Course

What Is Improving?

What Still Needs Work?

I understand this tool provides general guidance only, not legal advice. I will review the output before submitting my appeal and consult a professional if needed.

Your Appeal Text

Copy each section into the corresponding field on your appeal form.

Field 1: Why are you receiving the current services?

Field 2: Why do you feel it's too soon for your services to end?

Need Professional Help?

For complex cases, consider consulting an elder law attorney or getting free help from SHIP counselors.

NAELA - Find Elder Law Attorney Legal Aid (Free/Low-Cost) SHIP - Free Medicare Counseling Medicare.gov Appeals Info

Did this help? We built this tool because families need support during difficult times.

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