(Medicare Claims Processing Manual)

300.3 - The Responsibilities of the QIO  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  When an IRE notifies the QIO that a beneficiary has requested an expedited reconsideration, the QIO must supply all information that the IRE needs to make its expedited reconsideration as soon as possible, but no later than by close of business of the day that the IRE notifies the QIO of the request for the reconsideration.   At the beneficiarys request, the QIO must furnish the beneficiary with a copy of, or access to, any documentation that it sends to the IRE.  The QIO may charge the beneficiary a reasonable amount to cover the costs of duplicating the documentation and/or delivering it to the beneficiary.  The QIO must accommodate the request by no later than close of business of the first day after the material is requested.   300.4 - The Responsibilities of the Provider  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The provider may, but is not required to, submit evidence to be considered by an IRE in making its decision.  If a provider fails to comply with an IREs request for additional information beyond that furnished by the QIO for purposes of the expedited determination, the IRE makes its reconsideration decision based on the information available.   300.5 - Coverage During an Expedited Reconsideration  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  When a beneficiary makes a timely request for an expedited determination, the provider may not bill the beneficiary for any disputed services until the IRE makes its determination. Beneficiary liability for continued services is based on the QIOs decision.  400 - Part A Medicare Outpatient Observation Notice  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The MOON informs all Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or critical access hospital (CAH).   400.1 - Statutory Authority  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  On August 6, 2015, Congress enacted the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) Public Law 114 -42, amending Section 1866(a)(1) of the Social Security Act (the Act) (42 U.S.C. 1395cc(a)(1)), by adding a new subp aragraph (Y).  The NOTICE Act requires hospitals and CAHs to provide written and oral explanation of such written notification to individuals who receive observation services as outpatients for more than 24 hours.   The process for delivery of this notice, the Medicare Outpatient Observation Notice (MOON), was addressed in rulemaking, including a final rule, 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 489.20(y).   400.2 - Scope  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The MOON must be delivered to beneficiaries in Original Medicare (fee -for-service) and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours.  The hospital or CAH must provide the MOON no later than 36 hours af ter observation services as an outpatient begin.  This also includes beneficiaries in the following circumstances:    Beneficiaries who do not have Part B coverage (as noted on the MOON, observation stays are covered under Medicare Part B).   Beneficiaries who are subsequently admitted as an inpatient prior to the required delivery of the MOON.    Beneficiaries for whom Medicare is either the primary or secondary payer.    NOTES:    For purposes of these instructions, the term beneficiary means either beneficiary or representative, when a representative is acting for a beneficiary.    Please see Chapter 13 of the Medicare Managed Care Manual for Medicare Advantage instructions.   The statute expressly provides that the MOON be delivered to beneficiaries who receive observation services as an outpatient for more than 24 hours.  In other words, the statute does not require hospitals to deliver the MOON to all beneficiaries receiving outpatient services.   The MOON is intended to inform beneficiaries who receive observation services for more than 24 hours that they are outpatients receiving observation services and not inpatients, and the reasons for such status, and must be delivered no later than 36 hours  after observation services begin.  Howe ver, hospitals and CAHs may deliver the MOON to an individual receiving observation services as an outpatient before such individual has received more than 24 hours of observation services.  Allowing delivery of the MOON before an individual has received 24 hours of observation services affords hospitals and CAHs the flexibility to deliver the MOON consistent with any applicable State law that requires notice to outpatients receiving observation services within 24 hours after observation services begin.  The flexibility to deliver the MOON any ti me up to, but no later than, 36 hours after observation services begin also allows hospitals and CAHs to spread out the delivery of the notice and other hospital paperwork in an effort to avoid overwhelming and confusing beneficiaries.   Hospitals Affected by these Instructions.  These instructions apply to hospitals as well as CAHs per section 1861(e) and section 1861(mm) of the Social Security Act.  400.3 - Medicar e Outpatient Observation Notice  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The MOON is subject to the Paperwork Reduction Act (PRA) process and approval by the Office of Management and Budget (OMB).  The MOON may only be modified as per their accompanying instructions, as well as per guidance in this section.  Unapproved modifications cannot be made to the OMB -approved, standardized MOON.  The notice and accompanying instructions may be found online at http://www.cms.gov/Medicare/Medicare -General -Information/BNI   400.3.1 - Alterations to the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  In general, the MOON must remain two pages, unless inclusion of additional information per section 400.3.8 or State -specific information per section 400.5 below results in additional page(s).  Hospitals and CAHs subject to State law observation notice requirements may attach an additional page to the MOON to supplement the Additional Information section in order to communicate additional content required under State law, or may attach the notice required under State law to the MOON.  The pages of the notice can be two sides of one page or one side of separate pages, but must not be condensed to one page.   Hospitals may include their business logo and contact information on the top of the MOON.  Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, or any other information.   400.3.2 - Completing the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  Hospitals must use the OMB -approved MOON (CMS -10611). Hospitals must type or write the following information in the corresponding blanks of the MOON:    Patient name;   Patient number; and  Reason patient is an outpatient.  400.3.3 - Hospital Delivery of the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  Hospitals and CAHs must deliver the MOON to beneficiaries in accordance with section 400.2 above.  Hospitals and CAHs must provide both the standardized written MOON, as well as oral notification.   Oral notification must consist of an explanation of the standardized written MOON.  The format of such oral notification is at the discretion of the hospital or CAH, and may include, but is not limited to, a video format.  However, a staff person must alwa ys be available to answer questions related to the MOON, both in its written and oral delivery formats.   The hospital or CAH must ensure that the beneficiary or representative signs and dates the MOON to demonstrate that the beneficiary or representative received the notice and understands its contents.  Use of assistive devices may be used to obtain a signature.   Electronic issuance of the MOON is permitted.  If a hospital or CAH elects to issue a MOON 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 MOON, as specified in 400.3.9, and the required beneficiary specific information inserted, at the time of notice delivery.   400.3.4 - Required Delivery Timeframes  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The MOON must be delivered to a beneficiary who receives observation services as an outpatient for more than 24 hours, and must be delivered not later than 36 hours after observation services begin.  The MOON must be delivered before 36 hours following initiation of observation services if the beneficiary is transferred, discharged, or admitted.  The MOON may be delivered before a beneficiary receives 24 hours of observati on services as an outpatient.   The start time of observation services, for purposes of determining when more than 24 hours of observation services have been received, is the clock time observation services are initiated (furnished to the patient), as documented in the patients medical record, in accordance with a physicians order.  This follows the elapsed clock time, rather than the billed time, associated with the observation services.   400.3.5 - Refusal to Sign the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  If the beneficiary refuses to sign the MOON, and there is no representative to sign on behalf of the beneficiary, the notice must be signed by the staff member of the hospital or CAH who presented the written notification.  The staff members signature mus t include the name and title of the staff member, a certification that the notification was presented, and the date and time the notification was presented.  The staff member annotates the Additional Information section of the MOON to include the staff members signature and certification of delivery.  The date and time of refusal is considered to be the date of notice receipt.   400.3.6 - MOON Delivery to Representatives  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The MOON may be delivered to a beneficiarys appointed 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. http://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/downloads/cms1696.pdf .  See Chapter 29 of the Medicare Claims Processing Manual, section 270.1, for more information on appointed representatives.   The MOON may also be delivered to an authorized representative.  Generally, 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 medical power of attorney).   Notification to a beneficiary who has been deemed legally incompetent is typically made to an authorized representative of the beneficiary.  However, if a beneficiary is temporarily incapacitated, a person (typically, a family member or close friend) whom the hospital or CAH 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 MOON.  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.