(Medicare Claims Processing Manual)

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)   Preadmission: In preadmission situations, the beneficiary is liable, if admitted, for customary charges for all services furnished during the stay, except for those services for which he or she is eligible to receive payment under Part B.  Admission:  If the admission notice is issued at 3 p.m. or earlier on the day of admission, the beneficiary is liable for customary charges for all services furnished after receipt of the notice, except for those services for which the beneficiary is eligible to recei ve payment under Part B.   If the admission notice is issued after 3 p.m. on the day of admission, the beneficiary is liable for customary charges for all services furnished on the day following the day of receipt of the notice, except for those services for which the beneficiary is  eligible to receive payment under Part B.   240.3 - Timeframes for Submitting a Request for a QIO Review  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Preadmission:   In preadmission situations, a beneficiary who chooses to exercise the right to a QIO review should request immediately, but no later than 3 calendar days after receipt of the notice, or if admitted, at any point during the stay, an immediate review of the facts related to the admission.   Admission:   In admission situations, a beneficiary who chooses to exercise the right to a QIO review should request immediately, or at any point in the stay, an immediate review of the facts related to the admission.   240.4 - Results of the QIO Review  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  If the QIO disagrees with the hospitals determination  and says the stay is reasonable and necessary, the beneficiary will be refunded any amount collected except applicable coinsurance and deductibles, and convenience items or services not covered by Medicare.   If the QIO agrees with the hospital determination  and says the stay is not reasonable and necessary, the beneficiary will be responsible for all services on the date specified by the QIO.   240.5 - Effect of the QIO Review  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The QIO will send the beneficiary a formal determination of the medical necessity and appropriateness of the hospitalization determination is binding on the beneficiary, the physician, and hospital except in the following circumstances:   Right to pursue a reconsideration .  If the beneficiary is still an inpatient in the hospital and is dissatisfied with the determination, he or she may request a reconsideration according to the procedures described in 405.1204 (See Section 300 of this chapter.)   Right to pursue the general claims appeal process.     If the beneficiary is no longer an inpatient in the hospital, the determination is subject to the general claims appeal process (See Chapter 29 of this manual.)    240.6 - Exhibit 4  Model Language for Preadmission/Admission Hospital Issued Notice of Noncoveage  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Hospital Identifier   Preadmission or Admission Hospital -Issued Notice of Noncoverage (HINN)  Model Language    Name of Patient: ____________________Name of Physician:____________________  Patient ID Number: __________________Date Issued: _________________________   We believe that Medicare is not likely to pay for your admission for _____________________(specify service or condition)__________________ because:    ____it is not considered to be medically necessary    ____it could be furnished safely in another setting    ____other________________________________________________.  However, this notice is not an official Medicare decision.  If you disagree with our finding:    You should talk to your doctor about this notice and any further health care you may need.    You also have the right to an appeal, that is, an immediate review of your case by a Quality Improvement Organization (QIO).  The QIO is an outside reviewer hired by Medicare to make a formal decision about whether your admission is covered by Medicare.  See page 2 for instructions on how to request a review and contact the QIO.    If you decide to go ahead with the hospitalization, you will have to pay for: ________________________________________________________________1              CONTINUED ON PAGE 2   1 For preadmission notices, insert:  "customary charges for all services furnished during the stay, except for those services for which you are eligible under Part B."   For admission notices issued not later than 3:00 P.M. on the date of admission, insert:  "customary charges for all services furnished after receipt of this hospital notice, except for those services for which you are eligible under Part B."  (If these req uirements are not met, insert the liability phrase below.)  For admission notices issued after 3:00 P.M.  on the day of admission, insert:  "customary charges for all services furnished on the day following the day of receipt of this notice, except for those services for which you are eligible to receive payment under Part B."   If you want an immediate review of your case:    ________________(insert one of the following as appropriate)_____________  Preadmission:        Call the QIO immediately at the number listed below, but no later than 3 calendar days after you receive this notice.  If you are admitted, you may call the QIO at any point in the stay.  Admission:    Call the QIO immediately at the number listed below or you may call the QIO at any point during your stay.   You may also call the QIO for quality of care issues.  QIO Contact Information:  _______(insert name of QIO in bold)________________ _______(insert telephone number of QIO)_____________  If you do not want an immediate review:    You may still request a review within 30 calendar days from the date of receipt of this notice by calling the QIO at the number below.  Results of the QIO Review:    The QIO will send you a formal decision about whether your hospitalization is appropriate according to Medicares rules, and will tell you about your reconsideration and appeal rights.   IF THE QIO FINDS YOUR HOSPITAL CARE IS COVERED, you will be refunded any money you may have paid the hospital except for any applicable copays, deductibles, and convenience items or services normally not covered by Medicare.    IF THE QIO FINDS THAT YOUR HOSPITAL CARE IS NOT COVERED, you are responsible for payment for all services beginning on ______(specify date)____. (see footnote1  on page 1).    For more information, 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   260 - Expedited Determinations of Provider Service Terminations  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  260.1 - Statutory Authority  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  Section 1869(b)(1)(F) of the Social Security Act (the Act), as amended by section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub.  L. 106- 554) granted beneficiaries in Original Medicare the right to an expedited determination process to dispute the end of t heir Medicare covered care in certain provider settings.  This process was implemented though a final rule with comment period, CMS -4004- FC (69 FR 69252, November 26, 2004), effective July 1, 2005.  The resulting regulations are located at 42 CFR Part 405, 405.1200 -  405.1204.  There is a parallel process for beneficiaries enrolled in Medicare health plans. (See 90.2 -90.8 in Chapter 13 of the Medicare Managed Care Manual (CMS Pub. 100 -16.)  260.2 - Scope  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The expedited determination process is available to beneficiaries in Original Medicare whose Medicare covered services are being terminated in the following settings. All beneficiaries receiving services in these settings must receive a Notice of Medicare Non -Coverage (NOMNC) before their services end: For purposes of this instruction, the term beneficiary means either beneficiary or representative, when a representative is acting for a beneficiary.    Home Health Agencies (HHAs)    Comprehensive Outpatient Rehabilitation Services (CORFs)    Hospice    Skilled Nursing Facilities (SNFs) -- Includes services covered under a Part A stay, as well as Part B services provided under consolidated billing (i.e. physical therapy, occupational therapy, and speech therapy).  A NOMNC must be delivered by the SNF at the end of a Part A stay or when all of Part B therapies are ending. For example, a beneficiary exhausts the SNF Part A 100- day benefit, but remains in the facility under a private pay stay and receives physical and occupational therapy covered under Medicar e Part B.  A NOMNC must be delivered by the SNF when both Part B therapies are ending.   Skilled Nursing Facilities includes beneficiaries receiving Part A and B services in Swing Beds.   260.2.1 - Exceptions  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The following service terminations, reductions, or changes in care are not eligible for an expedited review.  Providers should not deliver a NOMNC in these instances.  When beneficiaries never received Medicare covered care in one of the covered settings (e.g., an admission to a SNF will not be covered due to the lack of a qualifying hospital stay or a face -to-face visit was not conducted for the initial episode of home health care).   When services are being reduced (e.g., an HHA providing physical therapy and occupational therapy discontinues the occupational therapy).   When beneficiaries are moving to a higher level of care (e.g., home health care ends because a beneficiary is admitted to a SNF).   When beneficiaries exhaust their benefits (e.g., a beneficiary reaches 100 days of coverage in a SNF, thus exhausting their Medicare Part A SNF benefit).   When beneficiaries end care on their own initiative (e.g., a beneficiary decides to revoke the hospice benefit and return to standard Medicare coverage).   When a beneficiary transfers to another provider at the same level of care (e.g., a beneficiary transfers from one SNF to another while remaining in a Medicare -covered SNF stay).   When a provider discontinues care for business reasons (e.g., an HHA refuses to continue care at a home with a dangerous animal or because the beneficiary was receiving physical therapy and the providers physical therapist leaves the HHA for another job).  260.3 - Notice of Medicare Non -Coverage  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The notice is subject to the Paperwork Reduction Act Process and approval by the Office of Management and Budget.  OMB -approved notices may only be modified as per their accompanying instructions.  Unapproved modifications may invalidate the NOMNC. The notice and accompanying instructions may be found online at http://www.cms.gov/Medicare/Medicare -General -Information/BNI   260.3.1 - Alterations to the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)