(Medicare Claims Processing Manual)

200.3.4.1 First IM   200.3.4.2 Follow -up copy of the IM  200.3.5 -  Refusal to Sign the IM  200.3.6 -  Amending the Date of the IM  200.3.7 -  IM Delivery to Representatives  200.3.8 -  Notice Retention for the IM  200.4 -  Expedited Determination Process   200.4.1 -  Beneficiary Responsibilities   200.4.1.1 -  Timeframe for Requesting an Expedited Determination   200.4.1.2 -  Provide Information to BFCC -QIO  200.4.2 -  Beneficiary Liability During BFCC -QIO Review  200.4.3 -  Untimely Requests for Review  200.4.4 -  Hospital Responsibilities  200.4.5 -  The Detailed Notice of Discharge (DND)  200.5 -  BFCC- QIO Responsibilities  200.5.1 -  Receive Beneficiary Requests for Expedited Review  200.5.2 -  Notify Hospitals and Allow Explanation of Why Covered Services Should End  200.5.3 -  Validate Delivery of IM  200.5.4 -  Solicit the Views of the Beneficiary  200.5.5 -  Solicit the Views of the Hospital  200.5.6 -  Make Determination and Notify Required Parties  200.6 -  Effect of a BFCC -QIO Expedited Determination  200.6.1 -  Right to Pursue an Expedited Reconsideration  200.6.2 -  Effect of BFCC -QIO Determination on Continuation of Care  200.6.3 -  Right to Pursue the Standard Claims Appeal Process  220 -  Hospital Requested Expedited Review  220.1 -  Responsibilities of the Hospital 220.2 -  Responsibilities of the QIO  220.3 -  Effect of the Hospital Requested Expedited Determination  220.4 -  General Notice Requirements  220.5 -  Exhibit 3 -  Model Language Notice of Hospital Requested Review (HRR)  240 -  Preadmission/Admission Hospital Issued Notice of Noncoverage (HINN)  240.1 -  Delivery of the Preadmission/Admission HINN  240.2 -  Notice Delivery Timeframes and Liability  240.3 -  Timeframes for Submitting a Request for a QIO Review  240.4 -  Results of the QIO Review  240.5 -  Effect of the QIO Review  240.6 -  Exhibit 4 -  Model Language Preadmission/Admission Hospital Issued Notice of Noncoverage  260 -  Expedited Determinations of Provider Service Terminations  260.1 -  Statutory Authority 260.2 -  Scope  260.2.1 -  Exceptions  260.3 -  Notice of Medicare Non -Coverage  260.3.1 -  Alterations to the NOMNC  260.3.2 -  Completing the NOMNC  260.3.3 -  Provider Delivery of the NOMNC  260.3.4 -  Required Delivery Timeframes  260.3.5 -  Refusal to Sign the NOMNC  260.3.6 -  Financial Liability for Failure to Deliver a Valid NOMNC  260.3.7 -  Amending the Date of the NOMNC  260.3.8 -  NOMNC Delivery to Representatives  260.3.9 -  Notice Retention for the NOMNC  260.3.10-  Hours of NOMNC Delivery  260.4 -  Expedited Determination Process  260.4.1 -  Beneficiary Responsibilities  260.4.1.1 -  Timeframe for Requesting an Expedited Determination  260.4.1.2 -  Provide Information to QIO  260.4.1.3 -  Obtain Physician Certification of Risk (Home Health and CORF services only)  260.4.2 -  Beneficiary Liability During QIO Review  260.4.3 -  Untimely Requests for Review  260.4.4 -  Provider Responsibilities  260.4.5 -  The Detailed Explanation of Non- Coverage  260.5 -  QIO Responsibilities  260.5.1 -  Receive Beneficiary Requests for Expedited Review  260.5.2 -  Notify Providers and Allow Explanation of Why Covered Services Should End 260.5.3 - Validate Delivery of NOMNC  260.5.4 -  Solicit the Views of the Beneficiary  260.5.5 -  Solicit the Views of the Provider  260.5.6 -  Make Determination and Notify Required Parties  260.6 -  Effect of a QIO Expedited Determination  260.6.1 -  Right to Pursue an Expedited Reconsideration 260.6.2 -  Effect of QIO Determination on Continuation of Care  260.6.3 -  Right to Pursue the Standard Claims Appeal Process  261 -  Expedited Determination Notice Association with Advance Beneficiary Notices  300 -  Expedited Reconsiderations  300.1 -  The Role of the Beneficiary and Liability  300.2 -  The Responsibilities of the IRE  300.3 -  The Responsibilities of the QIO  300.4 -  The Responsibilities of the Provider  300.5 -  Coverage During an Expedited Reconsideration 400 -  Part A Medicare Outpatient Observation Notice  400.1 -  Statutory Authority 400.2 -  Scope  400.3 -  Medicare Outpatient Observation Notice  400.3.1 -  Alterations to the MOON  400.3.2 -  Completing the MOON  400.3.3 -  Hospital Delivery of the MOON  400.3.4 -  Required Delivery Timeframes  400.3.5 -  Refusal to Sign the MOON  400.3.6 -  MOON Delivery to Representatives  400.3.7 -  Ensuring Beneficiary Comprehension  400.3.8 -  Completing the Additional Information Field of the MOON  400.3.9 -  Notice Retention for the MOON  400.4 -  Intersection with State Observation Notices  500- Glossary  10 - Financial Liability Protections (FLP) Provisions of Title XVIII  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  The FLP provisions of the Social Security Act (hereinafter referred to as the 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 afte r an item or services coverage determination is made.  This chapter discusses the following FLP provisions:    Limitation On Liability (LOL) under 1879(a) -(g) of the Act.    Refund Requirements (RR) for Non- assigned Claims for Physicians Services under 1842(l) of the Act.   Refund Requirements (RR) for Assigned and Non -assigned Claims for Medical  Equipment and Supplies under 1834(a)(18), 1834(j)(4), and 1879(h) of the Act.   In most cases, the FLP provisions apply only to beneficiaries enrolled in the Original Medicare FFS program Parts A and B.   The FLP provisions apply only when both of the following are met:    Items and/or services are denied on the basis of specific statutory or regulatory provisions.; and   Involve determinations about beneficiary and/or healthcare provider/supplier knowledge of whether Medicare was likely to deny payment for the items and/or services.    The LOL provisions apply to all Part A services and all assigned claims for Part B services.  The RR apply to both assigned and unassigned claims for medical equipment and supplies and to unassigned claims for physicians services.  However, RR do not apply to claims for Part A services.   20 - Limitation On Liability (LOL) Under 1879 Where Medicare Claims Are Denied  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19) In general, application of the LOL provisions depends upon two primary factors:  1. Whether the claim for the item and/or service provided was denied for certain specific reasons.  See 21 of this chapter for more examples.   Type of Denial  Description  Example  Statutory Basis  The LOL provisions apply only to claims for items and/or services submitted by healthcare providers or suppliers that have Items and services found to be not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the Type of Denial  Description  Example  taken assignment, and only to claims for items and/or services not otherwise statutorily excluded, that are denied on the basis of 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Act.  functioning of a malformed body member.  (1862(a)(1)(A) of the Act) Dependent Services  When Medicare payment is made under the LOL provisions, the payment determination includes claims for any dependent services that are denied as an indirect result of the original denial.  Thus, where a particular qualifying service is denied as not reasona ble and necessary under 1862(a)(1) (A) of the Act, any dependent services are also denied as not reasonable and necessary under 1862(a)(1)(A) of the Act.  If the LOL provisions apply to the denial of the qualifying service, it will also apply to the dependent service, and Medicare will mak e payment for both services, provided all other conditions for coverage and payment are met.  Under 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, home health aide services can be covered only if a beneficiary needs intermittent skilled nursing care.  When coverage is denied for intermittent skilled nursing services (the qualifying primary services)  under 1862(a)(1) or (9) of the Act, home health aide services (the dependent services) likewise are not covered.  In such cases, if Medicare payment is made under the LOL provision for the primary services, it would be made for the dependent services as well, provided the services meet all conditions for coverage and payment (i.e. a physicians certification of the need for the dependent services and proof that the services are reasonable and necessary).  Higher Levels of Care and Excess Components  Normally, Medicare payment is denied for items and/or services that are not reasonable and necessary on the basis of 1862(a)(1)(A) of the Act.  However, the LOL provisions may apply if a reduction in payment occurs because the furnished items or services are at a higher level of care and provide more extensive items or services than was reasonable and necessary to meet the needs of the beneficiary.  A deluxe or aesthetic feature of an upgraded item of medical equipment is an excess component.  Charge increases on the basis of purported premium quality services are not considered to be excess components since that would constitute circumvention of payment limits and applicable charging limits (e.g., limiting charges in the case of unassigned claims for physicians services and fee schedule amounts in the case of assigned claims).   2. Whether the beneficiary and/or the healthcare provider or supplier knew or could reasonably have been expected to know that the item or service was not covered.   Knowledge of the Non -covered Item/Service  Liability  Payment Responsibility  If the beneficiary knew, or should have known (e.g. a valid liability notice such as an ABN, Form CMS -R-131 was issued and the beneficiary consented to receiving the item or service).  Rests with the beneficiary  The beneficiary is responsible for making payment for the usual and customary charges to the healthcare provider or supplier for the denied item and/or service.   If the beneficiary did not know (and should not have known), and the healthcare provider or supplier knew, or should have known.  Rests with the healthcare provider or supplier  The beneficiary may not be charged for any costs related to the denied item and/or service, including copayments and deductibles.  If neither the beneficiary nor the healthcare provider or supplier knew, and could not reasonably be expected to have known.  Neither the beneficiary or the healthcare provider or supplier  The Medicare program makes payment for the assigned claim.   20.1 - LOL Coverage Denials (Rev. 1, 10- 01-03) (Rev.:4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  A.  Statutory Basis   The following table provides examples of denials based on 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Act: