(Medicare Claims Processing Manual)

The MOON may be delivered to a beneficiarys appointed representative. Appointed representatives are individuals designated by beneficiaries to act on their behalf.  A beneficiary may designate an appointed representative via the Appointment of Representative form, the CMS -1696. http://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/downloads/cms1696.pdf .  See Chapter 29 of the Medicare Claims Processing Manual, section 270.1, for more information on appointed representatives.   The MOON may also be delivered to an authorized representative.  Generally, an authorized representative is an individual who, under State or other applicable law, may make health care decisions on a beneficiarys behalf (e.g., the beneficiarys legal guardian, or someone appointed in accordance with a properly executed durable medical power of attorney).   Notification to a beneficiary who has been deemed legally incompetent is typically made to an authorized representative of the beneficiary.  However, if a beneficiary is temporarily incapacitated, a person (typically, a family member or close friend) whom the hospital or CAH has determined could reasonably represent the beneficiary, but who has not been named in any legally binding document, may be a representative for the purpose of receiving the MOON.  Such a representative should act in the beneficiarys best interests and in a manner that is protective of the beneficiary and the beneficiarys rights.  Therefore, a representative should have no relevant conflict of interest with the beneficiary.   In instances where the notice is delivered to a representative who has not been named in a legally binding document, the hospital or CAH annotates the MOON with the name of the staff person initiating the contact, the name of the person contacted, and the date, time, and method (in person or telephone) of the contact.  NOTE:   There is an exception to the in- person notice delivery requirement.  If the MOON must be delivered to a representative who is not physically present to receive delivery of the notice, the hospital or CAH is not required to make an off -site delivery to the representative.  The hospital or CAH must complete the MOON as requir ed an d telephone the representative.    The information provided telephonically includes all contents of the MOON;    Note the date and time the hospital or CAH communicates (or makes a good faith attempt to communicate) this information telephonically, per 400.2 above, to the representative is considered the receipt date of the MOON;    Annotate the Additional Information section to reflect that all of the information indicated above was communicated to the representative; and    Annotate the Additional Information section with the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.   Mail a copy of the annotated MOON to the representative the  day telephone contact is made.   A hard copy of the MOON must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g., FedEx, UPS).  The burden is on the hospital or CAH to demonstrate that timely contact was attempted with the representative and that the notice was delivered.   If the hospital or CAH and the representative both agree, the hospital or CAH may send the notice by fax or e -mail; however, the hospital or CAHs fax and e -mail systems must meet the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security requirements.  400.3.7 - Ensuring Beneficiary Comprehension  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The OMB -approved standardized MOON is available in English and Spanish.  If the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, hospitals and CAHs must employ their usual procedures to ensure notice comprehension.  Usual procedures may include, but are not limited to, the use of translators, interpreters, and assistive technologies.  Hospitals and CAHs are reminded that recipients of Federal financial assistance have an independent obli gation to provide language assistance services to individuals with limited English proficiency (LEP) consistent with section 1557 of the Affordable Care Act and Title VI of the Civil Rights Act of 1964.  In addition, recipients of Federal financial assistance have an independent obligation to provide auxiliary aids and services to individuals with disabilities free of charge, consistent with section 1557 of the Affordable Care Act and section 504 of the Re habilitation Act of 1973.  400.3.8 - Completing the Additional Information Field of the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  This section may be populated with any additional information a hospital wishes to convey to a beneficiary.   Such information may include, but is not limited to:    Contact information for specific hospital departments or staff members.    Additional content required under applicable State law related to not ice of observation services.   Part A cost -sharing responsibilities if a beneficiary is admitted as an inpatient before 36 hours following initiation of observation services.    The date and time of the inpatient admission if a patient is admitted as an inpatient prior to delivery of the MOON.    Medicare Accountable Care Organization information.   Hospital waivers of the beneficiarys responsibility for the cost of self -administered drugs.    Any other information pertaining to the unique circumstances regarding the particular beneficiary.   If a hospital or CAH wishes to add information that cannot be fully included in the Additional Information section, an additional page may be attached to supplement the MOON.   400.3.9 - Notice Retention for the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The hospital or CAH must retain the original signed MOON in the beneficiarys medical record.   The beneficiary receives a paper copy of the MOON that includes all of the required information described in section 400.3.2 and, as applicable, sections 400.3.5, 400.3.6 and 400.3.8.  Electronic notice retention is permitted.  400.4 - Intersection with State Observation Notices  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  As noted in sections 400.3.1 and 400.3.8 above, hospitals and CAHs in States that have State -specific observation notice requirements may add State -required information to the Additional Information field, attach an additional page, or attach the notice required under State law to the MOON.   500 - Glossary  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    The following terms are defined only for purposes of this Chapter 30 of the Medicare Claims Processing Manual.    Advance notice of non -coverage  42 CFR 418.408(d)(2) states that if Medicare would be likely to deny payment as not medically reasonable and necessary, before the service was provided, the physician informed the beneficiary, or someone acting on the beneficiary's behalf, in writing that the physician believed Medicare was likely to deny payment for the specific service and that the beneficiary signed a statement agreeing to pay for that service. This statement may appear as the  notice of non -coverage (e.g.  Advance Beneficiary Notice of Non -coverage (ABN), Form CMS -R-131, Skilled  Nursing Facility Advance Beneficiary Notice of Non- Coverage (SNF ABN), Form CMS10055, Home Health Change of Care Notice (HHCCN), Form CMS -10280), as defined in 42 CFR 411.404.)     Advance Beneficiary Notice of Non -coverage (ABN, Form CMS -R-131) -  Issued by healthcare providers and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied.     Authorized representative  An individual authorized under State or other applicable law, e.g., a legally appointed representative or guardian of the beneficiary (if, for example, the beneficiary has been legally declared incompetent by a court) to act on behalf of a beneficiary when the beneficiary is temporarily or permanently unable to act for himself or herself.  The authorized representative will have all of the rights and responsibility of a beneficiary or party, as applicable.  In states which have health care consent statutes providing for health care decision making by surrogates on behalf of patients who lack advance directives and guardians, reliance upon individuals appointed or designated under such statutes to act as authorized representatives is permissible.  The Appointment of Representative , Form CMS -1696 is available for the convenience of the beneficiary or any other individual to use when appointing a representative.      For purposes of this chapter, when the term beneficiary is used, for legal purposes, and the beneficiary has an authorized representative, the use of either beneficiary or authorized representative are exchangeable of each other, unless otherwise indicated.     Beneficiary  Individual who is enrolled to receive benefits under Medicare Part A and/or Part B.     Detailed Explanation of Non -Coverage (DENC, Form CMS -10124)  Medicare FeeFor -Service (FFS) Expedited Determination Notice given only if a beneficiary requests an expedited determination.  The DENC explains the specific reasons for the end of services.     Detailed Notice of Discharge (DND, Form CMS -10066)  Hospital Discharge Appeal Notice given to beneficiaries who choose to appeal a discharge decision from the hospital or their Medicare Advantage plan, if applicable.    Financial Liability Protections (FLP) Provisions  The FLP provisions of the Social Security Act protect beneficiaries, healthcare providers, and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay.  The FLP provisions apply after an  item or services coverage determination is made.     Healthcare provider  Healthcare provider means a provider of services (or provider) (as defined under Section 1861(u) of the Social Security Act), a hospital, a critical access hospital (CAH), a skilled nursing facility (SNF), a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization or intensive outpatient  services).     Home Health Change of Care Notice (HHCCN, Form CMS -10280) -  Used by Home Health Agencies (HHAs) to notify Original Medicare beneficiaries receiving home health care benefits of plan of care changes.  HHAs are required to provide notification to beneficiaries before reducing or terminating an item and/or service.     Hospital -Issued Notices of Non -coverage (HINNs) - Hospitals provide to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered by Medicare.     Important Message from Medicare (IM, Form CMS -R-193)  Hospital Discharge Appeal Notice delivered to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients.  The IM informs hospitalized inpatient beneficiaries of their hospital discharge  appeal rights.     Limitation on Liability (LOL) Provision  The LOL provisions, 1879(a) -(g) of the Social Security Act, fall under the FLP provisions and provide financial relief and protection to beneficiaries, healthcare providers, and suppliers by permitting Medicare payment to be made, or requiring refunds t o be made, for certain items and/or services for which Medicare payment would otherwise be denied.    Limitation on Recoupment  The requirement that (in certain cases) Medicare must cease or delay recovery of an overpayment when a valid first or second level appeal request is received from a provider on an overpayment, in accordance with Section 1893 of the Social Security Act.  For more information, see 100- 06 Medicare Financial Management Manual, Chapter 3, Overpayments.    Medicare Beneficiary Identifier (MBI) -  is a general term describing a beneficiary's  Medicare identification number.  Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that  will continue to use the HICN as part of their processes.    Medicare Contractor -  An entity that contracts with the Federal government to review and/or adjudicate claims, determinations and/or decisions.     Medicare Outpatient Observation Notice (MOON, Form CMS -10611) - A standardized notice to inform Medicare beneficiaries (including health plan enrollees) that they are outpatients receiving observation services and are not inpatients of a hospital or CAH.