(Medicare Claims Processing Manual)

Under the capped -rental method, if the contractor determines that the supplier is obligated to make a refund, the supplier must repay Medicare those rental payments that the supplier has received for the item.  However, the Medicare beneficiary must return  the item to the supplier.   200 - Expedited  Determinations of Inpatient Hospital Discharges        (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Medicare beneficiaries who are hospital inpatients have a statutory right to appeal to a BFCC- QIO for an expedited review when a hospital, with physician concurrence, determines that inpatient care is no longer necessary.   200.1 - Statutory Authority  (Rev. 11210; Issued: 01- 21-2022; Effective: 04 -21-2022; Implementation: 04- 21-2022)    Sections 1866(a)(1)(M),    1869(c)(3)(C)(iii)(III), and    1154(e) of the Act.   This process was implemented through a final rule with comment period, CMS -1655- F (81 FR 56761, 57037 through 57052, August 22, 2016), effective October 1, 2016.  The resulting regulations are located at 42 CFR Part 405.1205 and 405.1206).   There is a parallel process for beneficiaries enrolled in Medicare health plans. (See 42 CFR 422.620 -  422.622 and 100.1 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.) Please see the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance  for Medicare Advantage instructions.  200.2 - Scope  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   The expedited determination process is available to beneficiaries in Original Medicare who are being discharged from a Medicare covered inpatient hospital stay. All beneficiaries receiving covered inpatient hospital care must receive an Important Message from Medicare (IM). This includes, but is not limited to, beneficiaries in the following circums tances:    Beneficiaries for whom Medicare is either the primary or secondary payer.    Beneficiaries with brief inpatient hospital stays.   Beneficiaries physically discharged from the hospital or discharged to a lower level of care (such as a Swing Bed) in the same hospital.   NOTE:   For purposes of these instructions, the term beneficiary means either beneficiary or representative, when a representative is acting for a beneficiary.   Hospitals Affected by these Instructions.   These instructions apply to hospitals as well as Critical Access Hospitals (CAHs) per section 1861(e) and section 1861(mm) of the Social Security Act. CAHs, as well as psychiatric hospitals, are included in the scope of these instructions.   200.2.1 - Exceptions  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   The following situations are not eligible for an expedited determination.  Hospitals should not deliver an IM in these instances.    When a beneficiary transfers to another hospital at the same level of care (e.g., a beneficiary transfers from one hospital to another while remaining a hospital inpatient).    When beneficiaries exhaust their benefits (e.g., a beneficiary reaches the number of lifetime reserve days of the Medicare inpatient hospital benefit.)    When beneficiaries end care on their own initiative (e.g., a beneficiary elects the hospice benefit).   Condition Code 44 (CC44) (See Section 50.3 of Chapter 1 of the Medicare Claims Processing Manual )   Physician does not concur with discharge.  (See Section 220 of this chapter.)   NOTE:   The IM should only be given when an inpatient admission is pending or has occurred.  It should not be given just in case, such as a hospital delivering to all Medicare patients being treated in a hospital emergency room.   200.3 - Important Message from Medicare (IM)                                      (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   The IM is subject to the Paperwork Reduction Act (PRA) process and approval by the Office of Management and Budget (OMB).  The IM may only be modified as per the accompanying instructions, as well as per guidance in this section.  Unapproved modifications cannot be made to the OMB -approved, standardized IM.  The notice and accompanying instructions may be found online at Hospital Discharge Appeal Notices .  200.3.1 - Alterations to the IM  (Rev. 11210; Issued: 01 -21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    The IM must remain two pages.  The notice can be two sides of one page or one side of two separate pages, but must not  be condensed to one page.    Hospitals may include their business logo and contact information on the top of the IM. Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, etc.   Hospitals may include information in the optional Additional Information section relevant to the beneficiarys situation.   NOTE:   Including information normally included in the Detailed Notice of Discharge (DND) in the Additional Information section does not satisfy a hospitals responsibility to deliver the DND, if otherwise required. See 200.4.5 The Detailed Notice of Discharge  (DND).   200.3.2 - Completing the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    Hospitals must use the OMB -approved IM (CMS -10065). Hospitals must add the following information in the corresponding blanks of the IM:   1. Patient name   2. Patient number   3. BFCC- QIO contact information   NOTE:   The Patient number may be a unique medical record or other provider -issued identification number. It may not be the Social Security Number, HICN or any other Medicare number issued to the beneficiary such as the MBI (Medicare Beneficiary Identifier).   200.3.3 - Hospital Delivery of the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Hospitals must deliver the IM to all beneficiaries eligible for the expedited determination process per 200.2. An IM must be delivered even if the beneficiary agrees with the discharge.    The hospital must ensure that the beneficiary or representative signs and dates the IM to demonstrate that the beneficiary or representative received the notice and understands its contents.  See 200.3.7 Ensuring Beneficiary Comprehension.    Use of assistive devices may be used to obtain a signature.    Electronic issuance of the IM is permitted.    If a hospital elects to issue an IM viewed on an electronic screen before signing, the beneficiary must be given the option of requesting paper issuance over electronic issuance if that is what the beneficiary prefers.  Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the IM, as specified in 200.3.9, and the required beneficiary specific information must be inserted, at the time of notice delivery.   200.3.4- Required Delivery Timeframes  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   200.3.4.1 - First IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Hospitals must deliver the first copy of the IM at or near admission, but no later than 2 calendar days following the date of the beneficiarys admission to the hospital.  Hospitals may deliver the first copy of the notice if the beneficiary is seen during a preadmission visit, but not more than 7 calendar days in advance of admission.  A hospital must deliver the IM to all inpatients, including those in the hospital for a short stay.   Once the discharge date is planned, a hospital does not need discharge orders in advance of delivering the IM.   Timing of First IM Delivery    Pre-Admission   Up to 7 days before admission   At Admission   At admission   After Admission  Up to 2 days following admission    200.3.4.2 - Follow -Up Copy of the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Hospitals must deliver the follow up copy of the IM within 2 days of discharge.  It may be given as late as four hours prior to discharge.   However, if delivery of the first IM is within 2 calendar days of the date of discharge, no follow -up notice is required.  For example, if a beneficiary is admitted on Monday, the IM is delivered on Wednesday and the beneficiary is discharged on Friday, no follow -up notice is require d.   A hospital may deliver a new copy of the IM (not a copy of the signed IM) during the required timeframes; however, the hospital must obtain the beneficiarys or representatives signature and date on the notice again at that time, or    A hospital may deliver a copy of the signed, first IM with the date of delivery of the follow up copy indicated on the IM.   Timing of Follow -Up IM Delivery   No sooner than:  Two days before discharge   No later than:   Four hours prior to discharge    Notes:    If two or fewer days have passed since delivery of the first IM, no follow -up IM is required.    The follow -up IM may be copy of signed first IM and does not need to be re -signed.  200.3.5 - Refusal to Sign the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   If the beneficiary refuses to sign the IM the provider should annotate the notice to that effect, and indicate the date of refusal on the notice. The date of refusal is considered to be the date of notice receipt. Beneficiaries who refuse to sign the IM re main entitled to an expedited determination.  200.3.6 - Ensuring Beneficiary Comprehension  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    The OMB -approved standardized IM 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 obligat ion 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 Rehabilitation Act of 1973. 200.3.7 - IM Delivery to Representatives  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation:04- 21-2022)   The IM may be delivered to a beneficiarys appointed or authorized representative.  Types of Representative   Appointed Representative  Authorized 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.  See Chapter 29 of the Medicare Claims Processing Manual, section 270.1, for more information on appointed representatives.   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 me dical power of attorney).     Notes :