(Medicare Claims Processing Manual)

The QIO must validate that the NOMNC included the required elements outlined below:    Date that coverage of services ends.    Date that beneficiarys financial liability begins.    Description of right to an expedited determination (and how to request an expedited determination) and the right to submit relevant information to the QIO.    Right to detailed information on why the provider believes Medicare will no longer cover services.    Contact information for QIO in the state where services were delivered.   The QIO should determine  that NOMNC delivery was valid if all of the following criteria are met:    All elements stated above are included.    The beneficiary signed and dated the notice.  If the NOMNC was annotated because the beneficiary refused to sign the notice upon delivery, the QIO may still conduct an expedited determination in these instances.   Notice was delivered  at least two days before services terminate.  For a non -residential provider, the notice may be delivered at the next to last visit before services terminate.   Invalidating a NOMNC should be a rare occurrence.  The only reasons to invalidate are the lack of one of the criteria stated above or a pattern of minor errors as established by the provider.   If a QIO invalidates a NOMNC, a new NOMNC must be issued to the beneficiary with an effective date at least two days after the beneficiary receives valid notice.  If the beneficiary again disagrees with the termination of care, a new request to the QIO mus t be made.   260.5.4 - Solicit the Views of the Beneficiary  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO must solicit the views of the beneficiary who requested the expedited determination.   260.5.5 - Solicit the Views of the Provider  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO must afford the provider an opportunity to explain why the discharge is appropriate.   260.5.6 - Make Determination and Notify Required Parties  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  No later than 72 hours after receipt of the request for an expedited determination, the QIO must make its determination on whether the discharge is appropriate based on medical necessity or other Medicare coverage policies.   Note: If the QIO does not receive supporting information from the provider, it may make its determination based on the evidence at hand, or defer a decision until it receives the necessary information.  If this delay results in continued services for the benefic iary, the provider may be held financially liable for these services as determined by the QIO.   The QIO must notify the beneficiary, the beneficiarys physician, and the provider of services of its determination.  This notification must include the rationale for the determination and an explanation of Medicare payment consequences and beneficiary liability.  QIOs must also inform the beneficiary of the right to an expedited reconsideration by the Qualified Independent Contractor (QIC) and how to request a timely expedited reconsideration.  The QIO will make its initial notification via telephone and will follow up with a written determination letter.    260.6 - Effect of a QIO Expedited Determination  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO determination is binding unless the beneficiary pursues an expedited reconsideration per section 270 of this chapter.   260.6.1 - Right to Pursue an Expedited Reconsideration  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If dissatisfied with the expedited determination, the beneficiary may request an expedited reconsideration according to the procedures described in section 270 of this chapter.   260.6.2 - Effect of QIO Determination on Continuation of Care  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If the QIO decision extends coverage to a period where a physicians orders do not exist, either because of the duration of the expedited determination process, or because the physician has already concurred with the termination of care, providers cannot deliver care.   In the event of a QIO decision favorable to a beneficiary without physician orders, the ordering physician should be made aware the QIO has ruled coverage should continue, and be given the opportunity to reinstate orders.  The beneficiary ma y also seek other personal physicians to write orders for care as well as find another service provider. The expedited determination process does not override regulatory or State requirements that physician orders are required for a provider to deliver car e.  If a QIO decision is favorable to the beneficiary and the beneficiary resumes covered services, a new NOMNC should be delivered if that care is later terminated, per the requirements of this section.  If the beneficiary again disagrees with the termination  of care, a new request to the QIO must be made.   The QIO decision will affect the necessity of subsequent Advance Beneficiary Notice of Noncoverage (ABN) deliveries.   Example:  If covered home health care continues following a favorable QIO decision for the beneficiary, the HHA would resume issuance of Home Health Advanced Beneficiary Notices (HHABNs) as warranted for the remainder of this home health episode. If the QIO decides that Medicare covered care should end and the patient wishes to continue receiving care from the HHA, even though Medicare will not pay, an HHABN with Option Box 1 must be issued to the beneficiary since this would be an initiation of non-covered  care.   Example: If covered Skilled Nursing Facility (SNF) care continues following a favorable QIO decision for the beneficiary but later ends due to the end of Medicare coverage, and the patient wishes to continue receiving uncovered care at the SNF, a SNFABN must be issued to the beneficiary.   260.6.3 - Right to Pursue the Standard Claims Appeal Process  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If a beneficiary receives services of the type at issue in the expedited determination after the coverage end date, and coverage is denied, the beneficiary may appeal the denial within the standard claims appeal process (See Chapter 29 of this manual.)   261 - Expedited Determination Notice Association with Advance Beneficiary Notices  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs.  Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per 1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.   Only one notice may be required when Medicare covered care is ending.  Example: A beneficiary is receiving CORF services and all covered CORF care is ending. A NOMNC must be delivered at least two days, or two visits, prior to the end of coverage.  If the beneficiary does not continue the CORF services, an ABN should not be issued.  Some situations may require two notices at the end of Medicare covered care.   Example: A beneficiarys Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverag e.  A SNFABN must also be delivered before custodial care begins.   It is also possible that no notice is required when Medicare coverage is ending.  Example: A beneficiary exhausts the 100 day benefit in a SNF.  In this instance, the NOMNC should not be delivered. The SNFABN is not required in this situation.  However, it can be issued voluntarily, as a courtesy to the beneficiary.   300 - Expedited Reconsiderations  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  A beneficiary who is dissatisfied with a QIO determination can request a reconsideration by an independent review entity (IRE).  Such reconsiderations are codified in regulations effective July 1, 2005 (42 CFR 405.1204) but are familiar to inpatient hospit al providers as the process previously available under 1155 of the Act.  This reconsideration process is the same for hospital and non- hospital providers.  300.1 - The Role of the Beneficiary and Liability  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)   Submitting a Request :  A beneficiary who chooses to exercise the right to an expedited reconsideration must submit a request to the appropriate IRE in writing or by telephone no later than noon of the calendar day following the initial notification (whether by telephone or in writing) of the QIOs determination. The beneficiary, upon request  of the QIO, should be available to discuss the case or supply information that the IRE may request.  The beneficiary may, but is not required to, submit written evidenc e to be considered by the IRE.   Untimely Requests:  When the beneficiary fails to make a timely request for an expedited reconsideration subsequently may request a reconsideration under the standard claims appeal process (See Chapter 29 of this Manual), but the coverage protection described in Section 300.5 would not extend through this reconsideration, nor would the notification timeframes or the escalation process described in Section 300.2  apply.  300.2 - The Responsibilities of the IRE  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Receipt of the Request.   On the day the IRE receives the request for an expedited reconsideration, the IRE must immediately notify the QIO that made the expedited determination and the provider of services of the request for the expedited reconsideration.  Examine Records and Other Information . The IRE must offer the beneficiary and the provider an opportunity to provide further information.  Notification.  Unless the beneficiary requests an extension (see below), the IRE must notify the QIO, the beneficiary, and the provider of services of its decision no later than 72 hours after receipt of the request for an expedited reconsideration, and any such records  needed for the reconsideration.  The initial notification may be done by telephone followed by a written notice that includes:    The rationale for the reconsideration decision,  k  An explanation of the Medicare payment consequences of the determination and the beneficiarys date of liability,   Information about the beneficiarys right to appeal the IREs reconsideration decision to an ALJ, including how to request an appeal and the time period for doing so.  Escalation. Unless the beneficiary requests an extension, if the IRE does not issue a decision within 72 hours of receipt of the request, the IRE must notify the beneficiary of his or her right to have the case escalated to the ALJ hearing level if the amount remaini ng in controversy is $100 or more.   Extensions.  A beneficiary who requests an expedited reconsideration may request (either in writing or orally) that an IRE grant such additional time as the beneficiary specifies (not to exceed 14 days) for the reconsideration.  If an extension is granted, the deadlin es described above under notification, do not apply.  300.3 - The Responsibilities of the QIO  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  When an IRE notifies the QIO that a beneficiary has requested an expedited reconsideration, the QIO must supply all information that the IRE needs to make its expedited reconsideration as soon as possible, but no later than by close of business of the day that the IRE notifies the QIO of the request for the reconsideration.   At the beneficiarys request, the QIO must furnish the beneficiary with a copy of, or access to, any documentation that it sends to the IRE.  The QIO may charge the beneficiary a reasonable amount to cover the costs of duplicating the documentation and/or delivering it to the beneficiary.  The QIO must accommodate the request by no later than close of business of the first day after the material is requested.   300.4 - The Responsibilities of the Provider  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)