evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
260.5.5 - Solicit the Views of the Provider  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO must afford the provider an opportunity to explain why the discharge is appropriate.   260.5.6 - Make Determination and Notify Required Parties  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  No later than 72 hours after receipt of the request for an expedited determination, the QIO must make its determination on whether the discharge is appropriate based on medical necessity or other Medicare coverage policies.   Note: If the QIO does not receive supporting information from the provider, 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 benefic iary, the provider may be held financially liable for these services as determined by the QIO.   The QIO must 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.  QIOs must also inform the beneficiary of the right to an expedited reconsideration by the Qualified Independent Contractor (QIC) and how to request a timely expedited reconsideration.  The QIO will make its initial notification via telephone and will follow up with a written determination letter.    260.6 - Effect of a QIO Expedited Determination  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO determination is binding unless the beneficiary pursues an expedited reconsideration per section 270 of this chapter.   260.6.1 - Right to Pursue an Expedited Reconsideration  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If dissatisfied with the expedited determination, the beneficiary may request an expedited reconsideration according to the procedures described in section 270 of this chapter.
(Medicare Claims Processing Manual)
If dissatisfied with the expedited determination, the beneficiary may request an expedited reconsideration according to the procedures described in section 270 of this chapter.   260.6.2 - Effect of QIO Determination on Continuation of Care  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If the QIO decision extends coverage to a period where a physicians orders do not exist, either because of the duration of the expedited determination process, or because the physician has already concurred with the termination of care, providers cannot deliver care.   In the event of a QIO decision favorable to a beneficiary without physician orders, the ordering physician should be made aware the QIO has ruled coverage should continue, and be given the opportunity to reinstate orders.  The beneficiary ma y also seek other personal physicians to write orders for care as well as find another service provider. The expedited determination process does not override regulatory or State requirements that physician orders are required for a provider to deliver car e.  If a QIO decision is favorable to the beneficiary and the beneficiary resumes covered services, a new NOMNC should be delivered if that care is later terminated, per the requirements of this section.  If the beneficiary again disagrees with the termination  of care, a new request to the QIO must be made.   The QIO decision will affect the necessity of subsequent Advance Beneficiary Notice of Noncoverage (ABN) deliveries.   Example:  If covered home health care continues following a favorable QIO decision for the beneficiary, the HHA would resume issuance of Home Health Advanced Beneficiary Notices (HHABNs) as warranted for the remainder of this home health episode. If the QIO decides that Medicare covered care should end and the patient wishes to continue receiving care from the HHA, even though Medicare will not pay, an HHABN with Option Box 1 must be issued to the beneficiary since this would be an initiation of non-covered  care.
(Medicare Claims Processing Manual)
Example: If covered Skilled Nursing Facility (SNF) care continues following a favorable QIO decision for the beneficiary but later ends due to the end of Medicare coverage, and the patient wishes to continue receiving uncovered care at the SNF, a SNFABN must be issued to the beneficiary.   260.6.3 - Right to Pursue the Standard Claims Appeal Process  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If a beneficiary receives services of the type at issue in the expedited determination after the coverage end date, and coverage is denied, the beneficiary may appeal the denial within the standard claims appeal process (See Chapter 29 of this manual.)   261 - Expedited Determination Notice Association with Advance Beneficiary Notices  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs.  Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per 1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.   Only one notice may be required when Medicare covered care is ending.  Example: A beneficiary is receiving CORF services and all covered CORF care is ending. A NOMNC must be delivered at least two days, or two visits, prior to the end of coverage.  If the beneficiary does not continue the CORF services, an ABN should not be issued.  Some situations may require two notices at the end of Medicare covered care.   Example: A beneficiarys Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverag e.  A SNFABN must also be delivered before custodial care begins.
(Medicare Claims Processing Manual)
It is also possible that no notice is required when Medicare coverage is ending.  Example: A beneficiary exhausts the 100 day benefit in a SNF.  In this instance, the NOMNC should not be delivered. The SNFABN is not required in this situation.  However, it can be issued voluntarily, as a courtesy to the beneficiary.   300 - Expedited Reconsiderations  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  A beneficiary who is dissatisfied with a QIO determination can request a reconsideration by an independent review entity (IRE).  Such reconsiderations are codified in regulations effective July 1, 2005 (42 CFR 405.1204) but are familiar to inpatient hospit al providers as the process previously available under 1155 of the Act.  This reconsideration process is the same for hospital and non- hospital providers.  300.1 - The Role of the Beneficiary and Liability  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)   Submitting a Request :  A beneficiary who chooses to exercise the right to an expedited reconsideration must submit a request to the appropriate IRE in writing or by telephone no later than noon of the calendar day following the initial notification (whether by telephone or in writing) of the QIOs determination. The beneficiary, upon request  of the QIO, should be available to discuss the case or supply information that the IRE may request.  The beneficiary may, but is not required to, submit written evidenc e to be considered by the IRE.   Untimely Requests:  When the beneficiary fails to make a timely request for an expedited reconsideration subsequently may request a reconsideration under the standard claims appeal process (See Chapter 29 of this Manual), but the coverage protection described in Section 300.5 would not extend through this reconsideration, nor would the notification timeframes or the escalation process described in Section 300.2  apply.
(Medicare Claims Processing Manual)
300.2 - The Responsibilities of the IRE  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  Receipt of the Request.   On the day the IRE receives the request for an expedited reconsideration, the IRE must immediately notify the QIO that made the expedited determination and the provider of services of the request for the expedited reconsideration.  Examine Records and Other Information . The IRE must offer the beneficiary and the provider an opportunity to provide further information.  Notification.  Unless the beneficiary requests an extension (see below), the IRE must notify the QIO, the beneficiary, and the provider of services of its decision no later than 72 hours after receipt of the request for an expedited reconsideration, and any such records  needed for the reconsideration.  The initial notification may be done by telephone followed by a written notice that includes:    The rationale for the reconsideration decision,  k  An explanation of the Medicare payment consequences of the determination and the beneficiarys date of liability,   Information about the beneficiarys right to appeal the IREs reconsideration decision to an ALJ, including how to request an appeal and the time period for doing so.  Escalation. Unless the beneficiary requests an extension, if the IRE does not issue a decision within 72 hours of receipt of the request, the IRE must notify the beneficiary of his or her right to have the case escalated to the ALJ hearing level if the amount remaini ng in controversy is $100 or more.   Extensions.  A beneficiary who requests an expedited reconsideration may request (either in writing or orally) that an IRE grant such additional time as the beneficiary specifies (not to exceed 14 days) for the reconsideration.  If an extension is granted, the deadlin es described above under notification, do not apply.  300.3 - The Responsibilities of the QIO  (Rev. 1257, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)
(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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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).