(Medicare Claims Processing Manual)

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 :   However, if a beneficiary is temporarily incapacitated and there is no representative, a person (typically, a family member or close friend) whom the hospital 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 IM.  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 must annotate the IM 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.   Delivery to off -site representatives    If the IM must be delivered to a representative who is not physically present, the hospital is not required to personally deliver the IM or have the IM delivered via courier to the representative.  The hospital must complete the IM as required and may inst ead telephone the representativeand then mail the IM. The date and time of the telephone call is considered the receipt date of the IM.   The hospital must complete all  of the following actions.  1. Verbally convey all contents of the IM;    2. Note the date and time this information is communicated verbally;   3. Annotate the Additional Information section to reflect that IM was communicated verbally to the representative; and    4. 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.    5. Mail a copy of the annotated IM to the representative the day telephone contact is made.   A hard copy of the IM 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 to demonstrate that timel y contact was attempted with the representative and that the notice was delivered.   If the hospital and the representative both agree, the hospital 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 securi ty requirements.   200.3.8- Notice Retention for the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   The hospital or CAH must retain the signed IM in the beneficiarys medical record.  The beneficiary receives a paper copy of the IM that includes all of the required information described in this section.  Electronic notice retention is permitted.   Hospitals must also document delivery of the follow -up copy of the IM in the patient records, when applicable.  For example, hospitals may use the Additional Information section of the IM to document delivery of the follow -up copy by adding a line for the beneficiarys or representatives initials and date.   200.4 - Expedited Determination Process                                                         (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    200.4.1 - Expedited Determination Process  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022 )    200.4.1.1 - Timeframe for Requesting an Expedited Determination  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   A beneficiary who receives an IM and disagrees with the discharge may request an expedited determination by the appropriate BFCC -QIO for the state where the services were provided.  The beneficiary must contact the BFCC -QIO by midnight of the day of discha rge, before leaving the hospital.  The beneficiary may contact the BFCC -QIO by telephone or in writing.   200.4.1.2 - Provide Information to BFCC-QIO (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04 -21-2022)    The beneficiary must be available to answer questions or supply information requested by the BFCC- QIO.  The beneficiary may, but is not required to, supply additional information to the BFCC -QIO that he or she believes is pertinent to the case.   200.4.2 - Beneficiary Liability During BFCC -QIO Review                     (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   When the beneficiary makes a timely  request for a BFCC -QIO expedited determination per 200.4.1.1, the beneficiary is not financially responsible for inpatient hospital services (except applicable coinsurance and deductibles) furnished before noon of the calendar day after the date the beneficiary receives notification of the expedited determ ination from the BFCC -QIO.  Please see 200.5.6 for QIO notification requirements.   When Liability Begins   BFCC -QIO determination   Liability begins   Unfavorable to the beneficiary  Noon of the day after the BFCC -QIO notifies the beneficiary of the decision.     Favorable to the beneficiary   Once the hospital again determines that the beneficiary no longer requires inpatient care, determines a new last date of coverage and notifies the beneficiary with a follow -up copy of the IM.     200.4.3 - Untimely Requests for Review                                                     (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Untimely request timeframes   Beneficiary location  BFCC -QIO determination  Beneficiary in hospital   [may request expedited review anytime while in hospital]  BFCC -QIO will make its determination and notify the beneficiary, the hospital, and the physician of its determination within 2 calendar days after it receives all requested information.  Beneficiary left hospital   [may request expedited review within 30 days of discharge]  BFCC -QIO will make its determination and notify the beneficiary, the hospital, and the physician of its determination within 30 calendar days after it receives all requested information .   The coverage protections discussed in 200.4.2 do not apply to a beneficiary who makes an untimely request to the BFCC -QIO.   200.4.4 - Hospital Responsibilities  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    When a hospital is notified by a BFCC -QIO of a beneficiary request for an expedited determination, the provider must perform all of the following actions.   1. Deliver the beneficiary a DNC (see 200.4.5) as soon as possible, but no later than noon of the day after BFCC -QIO notification;   2. Supply the BFCC -QIO with copies of the IM and DNC as soon as possible, but no later than noon of the day after BFCC -QIO notification;   3. Supply all information, including medical records, requested by the BFCC -QIO.  The BFCC- QIO may allow this required information to be supplied via phone, writing, or electronically.   If supplied via phone, the provider must keep a written record of the information it provides within the patient record; and  4. Furnish the beneficiary, at their request, with access to or copies of any documentation it provides to the BFCC -QIO.  The hospital may charge the beneficiary a reasonable amount to cover the costs of duplicating and delivering the documentation.  This doc umentation must be provided to the beneficiary by close of business of the first day after the material is requested.  200.4.5 - The Detailed Notice of Discharge (DND)                                             (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)  The Detailed Notice of Discharge (DND) is subject to the Paperwork Reduction Act (PRA) process and approval by the Office of Management and Budget (OMB).  The DND may only be modified as per the accompanying instructions, as well as per guidance in this se ction.  Unapproved modifications cannot be made to the OMB -approved, standardized DND.  The notice and accompanying instructions may be found online at https://www.cms.gov/Medicare/Medicare -General -Information/BNI/HospitalDischargeAppealNotices  Hospitals are responsible for the delivery of the DND to beneficiaries who request an expedited determination by the BFCC -QIO.  The DND must contain all the following information:  1. The facts specific to the beneficiarys discharge and providers determination that coverage should end.   2. A specific and detailed explanation of why services are either no longer reasonable or necessary or no longer covered.   3. A description of, and citations to, the Medicare coverage rule, instruction, or other policies applicable to the review.  The delivery must occur in person by noon of the day after the BFCC -QIO notifies the provider that the beneficiary has requested an expedited determination.  The DND does not require a signature but should be annotated in the event of a beneficiarys refusal to accept the notice upon delivery.  200.5  BFCC -QIO Responsibilities  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04 -21-2022)   200.5.1 - Receive Beneficiary Requests for Expedited Review                      (Rev.  11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)  BFCC- QIOs must be available to receive beneficiary requests for review 24 hours a day, 7 days a week.  200.5.2 - Notify Hospitals and Allow Explanation of Why Covered Services Should End                                                                                                 (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   When the BFCC -QIO receives a request from a beneficiary, the BFCC -QIO must immediately notify the provider of services that a request for an expedited determination was made.  If the request is received after normal working hours, the BFCC -QIO should notify the provider as soon as possible on the morning after the request was made.   200.5.3 - Validate Delivery of the IM  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   The BFCC- QIO should determine that IM delivery was valid if all of the following criteria are met:    The notice used is the OMB approved IM published by CMS.  The notice was delivered timely per 200.3.4.  The notice was signed and dated by the beneficiary.   If the BFCC -QIO determines that the hospital did not deliver a valid notice, the BFCC -QIO will provide education to the hospital on valid notice requirements.  200.5.4 - Solicit the Views of the Beneficiary                                                      (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)    The BFCC- QIO must solicit views of the beneficiary who requested the expedited determination.   200.5.5 - Solicit the Views of the Hospital                                                (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)