evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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 )
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing 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:_________________________  ______________________________________________________________________
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
____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)_____________
(Medicare Claims Processing Manual)
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).
(Medicare Claims Processing Manual)
 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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
 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).
(Medicare Claims Processing Manual)
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)  The NOMNC must remain two pages.  The notice can be two sides of one page or one side of two separate pages, but must not  be condensed to one page.   Providers may include their business logo and contact information on the top of the NOMNC. Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, etc.   Providers may include information in the optional Additional Information section relevant to the beneficiarys situation.   Note:  Including information normally included in the Detailed Explanation of Non-Coverage (DENC) in the Additional Information section does not satisfy a providers responsibility to deliver the DENC, if otherwise required.  260.3.2 - Completing the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)