(Medicare Claims Processing Manual)

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)   The BFCC- QIO must afford the provider an opportunity to explain why the discharge is appropriate.   200.5.6 - Make Determination and Notify Required Parties                             (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   No later than one calendar day after it receives all requested information, the BFCC -QIO must make its determination on whether the discharge is appropriate based on medical necessity or other Medicare coverage policies.  The BFCC- QIO must perform the following actions.  1. 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.   2. Inform the beneficiary of the right to an expedited reconsideration by the BFCC -QIO and how to request a timely expedited reconsideration.  3. Make its initial notification via telephone and follow up with a written determination letter.   NOTE:   If the BFCC -QIO does not receive supporting information from the hospital, 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 beneficiary, the provider may be held financially liable for these services as determined by the BFCC -QIO.   200.6 - Effect of a BFCC -QIO Expedited Determination                        (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation:0 4- 21-2022)   The BFCC- QIO determination is binding unless the beneficiary pursues an expedited reconsideration per section 300 of this chapter.   200.6.1 - Right to Pursue an Expedited Reconsideration                         (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)  If dissatisfied with the expedited determination, the beneficiary may request an expedited reconsideration according to the procedures described in section 300 of this chapter.   200.6.2 - Effect of a BFCC -QIO Determination on Continuation of Care  (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   A beneficiary may choose to remain in the hospital beyond the last day of coverage, but may be liable for services after that day.  The hospital should issue a Hospital -Issued Notice of Non- coverage (HINN 12) to inform the beneficiary of potential liability.  Please see (https://www.cms.gov/Medicare/Medicare -General -Information/BNI/HINNs) for HINN delivery instructions.  200.6.3 - Right to Pursue the Standard Claims Appeal Process              (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022 )  If the beneficiary is no longer an inpatient in the hospital and is dissatisfied with this determination, the determination is subject to the general claims appeal process (See Chapter 29 of this manual.).  220 - Hospital Requested Expedited Review  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  When a hospital determines that a beneficiary no longer needs inpatient care, but is unable to obtain the agreement of the physician, the hospital may request a QIO review.  Hospitals must notify the beneficiary that the review has been requested.  These instructions stem directly from Section 1154(e) of the Act and 42 CFR Par t 405.1208.  220.1 - Responsibilities of the Hospital  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The hospital must comply with the following procedures when requesting a QIO review:   Notify the Beneficiary .  Hospitals must notify the beneficiary that the hospital has requested a review using a model language notice called the Hospital Requested Review (HRR) described in this section.  See Section 220.4 for General Notice Requirements.  Supply information to the QIO .  Hospitals must supply any pertinent information the QIO  needs to conduct its review and must make it available by phone or in writing, by close of business on the first full day immediately following the day the hospital submits the request for review.   220.2 - Responsibilities of the QIO  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The QIOs responsibilities are as follows:  Receive request and examine records.   The QIO must notify the hospital that it has received the request for review and must notify the hospital if it has not received pertinent records, examine the pertinent records pertaining to the services, and solicit the views of the beneficiary.   Issue a determination.   QIOs make their determinations based on criteria in 1154(a) of the Act, which specifies that QIOs will determine whether:    the services are reasonable and medically necessary,    the services meet professionally recognized standards of care, and    the services could be safely be delivered in another setting.  The QIO will make a determination and notify the beneficiary, the hospital, and the physician of its decision within 2 days of the hospitals request and receipt of any pertinent information submitted by the hospital.   Notification.   When the QIO issues the determination, it must notify the beneficiary, the hospital, and the physician of its decision by telephone and subsequently in writing. The written notice of the expedited initial determination must contain the following:   The basis for the determination;    A detailed rationale for the determination;    A statement explaining the Medicare payment consequences of the expedited determination and the date of liability if any; and    A statement informing the beneficiary of his or her appeal rights and the timeframe for requesting an appeal.   220.3 - Effect of the Hospital Requested Expedited Determination  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The expedited determination is binding on the beneficiary, physician, and hospital, except in the following circumstances:   When the beneficiary remains in the hospital.   When the beneficiary is still an inpatient in the hospital and is dissatisfied with this determination, he or she may request a reconsideration according to the procedures described in Section 300 of this Chapter.  When the beneficiary is no longer an inpatient in the hospital.  If the beneficiary is no longer an inpatient in the hospital and is dissatisfied with this determination, this determination is subject to the general claims appeal process (See Chapter 29 of this manual).   220.4 - General Notice Requirements  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Providers should use the HRR to notify a beneficiary that it has requested a QIO review.  This notice can be found at  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/  Since the HRR uses model language, providers have some flexibility in the preparation of this notice.  However, it is highly recommended that hospitals use the model language provided in this instruction, or by their QIO, in order to avoid questions of i nvalid notice.  Providers should utilize the General Notice Requirements in Section 200.5 and the Translation requirements in Section 200.6.1 when preparing the notice.   220.5 - Exhibit 3  Model Language for Notice of Hospital Requested Review  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Hospital Identifier   Model Notice of Hospital Requested Review (HRR)   Name of Patient: ____________________Name of Physician:____________________  Patient ID Number: __________________Date Issued:_________________________  ______________________________________________________________________   We believe that Medicare will not continue to cover your hospital care because these services are no longer considered medically necessary in your case.  Because your doctor disagreed with our finding, the hospital is asking the quality improvement organiz ation (QIO) to review your case.  The QIO is an outside reviewer hired by Medicare to look at your case to decide if you are ready to leave the hospital. The name of the QIO is ____ (insert the name of the QIO)_________________.    The QIO will contact you to solicit your views about your case and the care you need.    You do not need to take any action until you hear from the QIO.   For more information about this notice, call 1- 800-MEDICARE (1 -800-633-4227), or  TTY: 1 -877-486-2048.   Please sign your name, the date and time.  Your signature does not mean that you agree with this notice, just that you received the notice and understand it.  __________________________________   __________      ________  Signature of Patient or Representative    Date       Time  240 - Preadmission/Admission Hospital Issued Notice of Noncoverage (HINN)  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Regulations found at 42 CFR Part 476.71 require QIOs to review the medical necessity of hospital discharges and admissions , in addition to other requirements specified in that section of the regulation.  Therefore, a  beneficiary has a right to request an expedited review by the QIO when a hospital (acting directly or through its utilization review committee) has determined at the time of preadmission or admission, that the beneficiary is facing a non- covered hospital stay because the services are not consid ered to be reasonable and necessary in this case, the services could be safely provided in another setting, or the care is considered custodial in nature.  The utilization review committee or the hospital may issue a preadmission/admission HINN.  QIOs may also issue such notices after having been contacted by a hospital regarding care believed to be medically unnecessary, inappropriate, or custodial.   The hospital need not obtain the attending physician's concurrence, or the QIO's, prior to issuing the preadmission/admission HINN.  This also applies to direct admissions to swing beds (i.e., the beneficiary is admitted to the swing bed when the hospital determ ines that the beneficiary does not need hospital -level care, but instead needs only skilled nursing (SNF) or custodial nursing (NF) level services).   240.1 - Delivery of the Preadmission/Admission HINN  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  When delivering the Preadmission/Admission HINN, hospitals must follow the notice delivery requirements in Section 200.3.1 regarding:    In-Person Delivery,   Notice Delivery to Representatives,   Ensuring Beneficiary Comprehension.   Beneficiary Signature and Date.   Refusal to Sign.  Notice Delivery and Retention.  240.2 - Notice Delivery Timeframes and Liability  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)