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Denial of Service

There are three situations when an individual can be denied hospital service:

  • Medical Criteria: An individual does not meet the medical criteria for that service (for example, a cancer treatment regimen).
  • Level of Service Criteria: An individual does not meet the criteria for a specific level of service (for example, a surgical procedure that can be done on an out-patient basis and the patient wishes to remain hospitalized).
  • Insurance: An individual's insurance does not cover that medical treatment or procedure (for example, the insurance company considers the treatment experimental or ineffective).

If your loved one encounters one of the above situations, there are options to pursue.

Medical Criteria

If your loved one does not meet the medical criteria for a service:

  • Talk with the doctor and review your loved one's medical situation.
  • Seek a second opinion. (Most insurance companies will reimburse for a second opinion; check with your health plan.)

Level of Service Criteria

If your loved one does not meet the level of service criteria:

  • Talk to the physician so that you have a clear understanding of the medical services needed and the reasons that the service is not an in-patient procedure.
  • Ask for the denial in writing.
  • Call the Peer Review Organization (the Delmarva Foundation) to request a review of the service denial if the patient has Medicare.
  • Contact the health insurance plan directly to appeal the decision if the patient is covered by a private health plan, not by Medicare.

Insurance

If your loved one's insurance does not cover a procedure or treatment:

Denial of Continued Stay

If your loved one is hospitalized and receives a denial of continued stay:

  • Talk to the nurse, social worker or discharge planner. He or she can speak with the Utilization Reviewer to clarify the reasons for the denial of additional days of hospitalization.
  • Ask for a second internal review, but be aware that the patient will be financially responsible for paying all charges connected with the denied portion of the stay if the appeal is not upheld.
  • Contact the Delmarva Foundation to appeal the decision if the patient is a Medicare recipient. After appealing the continued stay denial, the patient has the right to two (2) discharge-planning days in the hospital from the time he or she receives the “Continued Stay Denial” letter. (The patient cannot be billed for the approved discharge planning days while an appeal is in process.) This follows the same process for appealing a discharge.
  • Contact your loved one's health plan directly if Medicare does not cover him or her.