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 Northeast Health Care
Quality Foundation
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The
QIO for Maine, New
Hampshire and Vermont
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HOSPITAL ISSUED NOTICES and QIO
REVIEW
Printable
Pages
This
transmittal applies to the following hospital settings:
Acute Care Hospital Settings:
·
DRG
reimbursed acute care beds/general acute care hospitals
·
Non-DRG
reimbursed acute care beds
·
Critical access hospitals (CAHs)
·
Specialty hospitals/units (psychiatric and acute
rehabilitation)
Non Acute Care Hospital Settings:
·
Skilled swing beds
Hospitals may issue a
notice of non-coverage if they determine that the care the patient is
receiving, or is about to receive, is not covered because it is not medically
necessary, is not delivered in the appropriate setting or is custodial in
nature. This transmittal focuses on the
following Fee for Service (FFS) notices of non-coverage that are subject to QIO
review and that provide the patient appeal rights with the QIO.
Preadmission notice - issued before the patient is admitted to an
acute care setting bed
Admission notice - issued upon admission to an acute care setting bed
Late admission notice - issued during the patient’s stay while in an acute
care bed
Generic/expedited determination (ED) notice – issued when skilled services in SNF swing beds are
being terminated
Important Message – issued to all Medicare patients on admission and within two days of
discharge. This notice advises patients
of their discharge appeal rights. The
Important Message replaces the previous version of the Important Message and
the use of continued stay notices of non-coverage. Although the Important Message is not a notice of non-coverage
and does not provide notification of liability, it will be addressed in this
transmittal as it does provide QIO appeal rights.
The statutory authorities applicable to review of Hospital Issued Notices
of Non-coverage (HINNs) are found at 1154(e) and 1879 of the Social Security
Act. The regulatory authorities for
issuing HINNs are found at 42CFR 489.34, 411.404 and 412.42(c). The regulatory authorities for issuing
notices will be found at 42CFR 405.1200 – 1206.
Further information
about these notices may be found in the CMS manuals, in particular Chapter 30
of the Claims Processing Manual (http://www.cms.hhs.gov/manuals/),
and at CMS’s Beneficiary Notice Initiative web site at http://www.cms.hhs.gov/bni/. Please note that these web
sites also contain information about other types of notices not subject to QIO
review. The CMS Manuals and web sites
are the official source of information on notices of non-coverage. NHCQF’s transmittal is meant to supplement
the official information and provide clarification based on frequently asked
questions from the hospital community.
Types of Notices, Time of Issuance, and Patient
Liability 19
Requirements for Issuing a Notice of
Non-coverage 21
Amendments/Corrections/Rescissions/"Deemed"
Admissions/Reinstatements 28
Skilled Level of Care in
Hospitals without SNF Swing Beds 30
Skilled Level of Care in Hospitals with
SNF Swing Beds 32
Patient
Request for QIO Review (Appeal) 36
Reconsideration
of Notice Review Determinations 39
Summary Chart for Issuing
Notices 43
Model
Notices 47
Types of Notices, Time of
Issuance and Patient Liability
Click
here to access Listing of Model Letters.
Preadmission,
Admission and Late Admission Notices
Selection of the appropriate admission notice
depends on when the notice is being issued in relation to when the patient is
admitted to the hospital. NHCQF uses
the admission time determined by the hospital and documented on the hospital
face sheet created at the time of admission.
The admission time is usually recorded to the right of the admission
date on the face sheet. In the absence
of an admission face sheet, NHCQF uses the admission time documented on the
physician’s order to admit the patient.
A preadmission notice may be issued at any
time up to and including on the day of admission to the hospital as long as it
is issued before the official admission time.
If admitted, the patient is liable for all services rendered during the
stay. Once a patient is admitted to the
hospital, a preadmission notice is not an appropriate type of notice to issue.
An admission notice may be issued on the day
of admission after the patient has been admitted to the hospital but at
or before 3:00 p.m. The patient is
liable for all services rendered after the notice is received.
A late admission notice may be issued after
admission at any time after 3:00 p.m. on the day of admission or on any
subsequent day of the hospital stay.
The patient is not liable for charges until 12 noon on the day following
receipt of the notice of non-coverage.
The hospital will be held liable for non-covered services furnished from
day of admission through the day of notification.
Important Message
All hospitals are required to issue a revised
Important Message/Notice of Hospital Discharge Appeal Rights (CMS-R-193) to all
Medicare patients within 2 calendar days of admission or 7 calendar days prior
to admission. The notice must include
NHCQF contact information for appeal requests.
As NHCQF does not have a TTY number, hospitals should enter the state
relay number 711 instead of a TTY number.
A follow up copy of the notice must be delivered within 2 calendar days
of discharge. Patients who choose to
exercise their QIO appeal rights must receive a Detailed Notice (CMS 10066)
explaining the reasons why Medicare covered services should end.
The following are situations where delivery of the
followup copy of the notice is not required:
·
The patient is
discharged within two days of receipt of the initial notice
·
The patient is being
transferred to another acute care setting
·
The patient has
elected the hospice benefit while in the hospital
·
The patient’s
benefits are exhausted
·
The patient leaves
the hospital against medical advice.
The Important Message indicates that the patient
may be liable for services received after the planned discharge date, but does
not assign liability to the patient. If
the patient remains in the hospital after the planned discharge date, the
hospital must issue a continued stay notice, CMS HINN #12, on the morning after
the planned discharge date to assign liability to the patient. This notice should be used to specify the
date of the patient’s liability. CMS
HINN #12 must also be issued if the patient decides to stay in the hospital
after a QIO appeal upholding the discharge date. In this case, CMS HINN #12 may be issued as soon as the QIO
decision is received, with liability to begin noon of the day following
completion of the QIO review.
Note: CMS HINN #12 does not provide QIO appeal
rights. CMS HINN #12 is for use only
until CMS finalizes a hospital ABN for assigning patient liability.
Generic/Expedited
Determination (ED) Notices (Hospitals with Skilled Swing Beds Only)
When skilled services for
patients in SNF swing beds are going to be terminated, a notice (CMS 10123)
must be issued. The notice must be
issued at least two days prior to the last day that skilled services will be
covered. The patient’s liability will
begin on the day after the “effective date” recorded on the notice. (The “effective date” is the last day that
skilled services will be covered and this date must be entered on the
notice.) For example, if the effective
date is Wednesday, the notice must be issued at least by Monday and the
patient’s liability would begin on Thursday.
Patients who choose to exercise
their QIO appeal rights must receive a Detailed Notice (CMS 10124) explaining
the reasons why Medicare covered services should end.
Requirements for Issuing a
Notice of Non-coverage
A.
When physician concurrence is required to issue a
notice
B.
Attending physician does not give concurrence
A.
Issuing the Notice to the Appropriate Person
1. Patient understands
2. Patient doesn’t understand
a.
Patient
representative
b.
No patient
representative
B.
Providing Notification
1.
Verbal notification in
person
a.
Acknowledgment of
receipt
b.
Refusal to sign
2.
Verbal notification by
telephone
3.
Notification by certified
mail (patient representative not available in person or by telephone)
I.CONCURRENCE
The hospital must have the attending physician's
verbal or written concurrence for discharge before issuing the followup copy of
the Important Message.
The hospital may issue preadmission, admission,
late admission notices or Generic/ED notices of non-coverage without the
concurrence of the attending physician.
The hospital utilization review committee/staff may issue these notices
based on Medicare coverage guidelines, CMS notices or QIO notices/information. Except for Generic/ED notices, either a
hospital representative or a physician must sign the notice.
B. Attending Physician Does Not Give Concurrence for
Discharge
A hospital may request NHCQF to review a patient's
medical record to determine if discharge is appropriate if:
1.
The hospital
Utilization Review Committee/physician has determined that the patient's
hospital stay is no longer medically necessary; and
2.
The hospital's
Utilization Review physician has discussed the case with the attending physician
who disagrees with the hospital's determination.
To initiate QIO review the hospital must:
1.
Notify the patient in
writing that a QIO review of the stay is being requested because the attending
physician disagrees with the hospital’s issuing of the notice of non-coverage;
(copy provided with the model notices NHCQF
#32.)
2.
Complete a referral
form (copy provided with the model notices NHCQF
#31); and
3.
Submit a copy of the
patient notification letter and the completed referral form to the NHCQF office
with a complete copy of the patient's medical record.
NHCQF will complete the review within two calendar days of receipt of all necessary
information and will advise the hospital of the outcome.
If NHCQF approves the case for continued Medicare
coverage, no further hospital action is necessary.
If NHCQF agrees with the
hospital and denies Medicare coverage for the continued stay, issue CMS HINN
#12 to assign patient liability if the patient decides to remain in the
hospital.
II.ISSUING THE NOTICE
A.
Issuing the
Notice to the Appropriate Person
The hospital must advise
the appropriate person verbally and in writing of the non-covered services or
change in patient status and the appeals process. In order for the hospital to effectively provide notification and
transfer liability to the patient, the hospital must appropriately issue the notice.
Appropriate issuance applies to all notices, including the initial and
followup copy of the Important Message.
Appropriate notifications are considered to have
been made when the notice/Important Message is issued to the appropriate person
and:
1.
The notice was
explained and provided in person; or
2.
Telephone verbal
notice was provided and the written notice mailed on that same day (date
notification is considered received is determined by which of these events
occurred last if not done on the same day); or
3.
No verbal notice was
provided and the written notice is mailed by certified mail (the date the
certified letter is signed for or refused is considered to be the date
notification is received).
NOTE: If
both the hospital and the representative agree, hospitals may send the notice
by fax or email; however, hospitals must meet the HIPAA privacy and security
requirements.
The following guidelines
must be followed for deciding to whom to issue the notice:
1.
Patient Can
Understand Notice/Important Message
The medical record must provide documentation that
the patient is able to understand the meaning of the notice of
non-coverage/Important Message, the financial ramifications and the appeals
mechanism. If this is the case, the
notice/Important Message may be issued either to the patient or to his/her
power of attorney, if one exists.
(Hospitals should be careful not to give notices or the Important
Message to patients who for the most part are not capable of handling their own
affairs, but who happen to be having a "good" day when they appear
lucid.) See section 2 below for more
details.
If the patient requests that the notice/Important Message
be issued to someone else (instead of themselves), document the request on the
acknowledgment form or in the medical record and issue the notice to the
designated representative. The
representative must receive acceptable verbal notice and a copy of the
notice/Important Message as described in this section. Except for the Generic/ED notice and the
Important Message, the notice should be addressed to the person who is
receiving the notice.
After the notice/Important Message has been issued
to a patient, if the patient requests that an extra copy of the
notice/Important Message be provided to another person such as a family member,
the hospital should make every effort to do so. However, verbal notification is not required.
2.
Patient Cannot
Understand Notice/Important Message
If the patient is not able to understand the
meaning of the notice of non-coverage/Important Message, the hospital must
issue the notice/Important Message to a patient representative. The hospital is responsible for determining
whether the patient is mentally competent and capable of handling his/her own
business affairs and for determining the appropriate recipient of the
notice/Important Message.
If
the medical record indicates questionable cognitive loss, memory deficits
and/or impaired decision making skills, the hospital must determine whether a
patient is or is not able to comprehend the impact of the notice. If clinical documentation supports
intermittent confusion, poor memory, “alert but not oriented” or inability to
make needs known, the cognitive status of the patient may be in question. These notations would lead to a questionable
status of the patient’s ability to comprehend the impact of notice of non-coverage/Important
Message.
a.
Choosing a Patient
Representative
The usual order of priority in
choosing a representative is:
·
Legal appointee such
as DPOA, POA, legal or public guardian
·
Spouse, unless
legally separated
·
Adult child or parent
·
Other relatives
·
Close friend
However, hospitals should be careful in selecting a
representative. A spouse may also have
problems understanding the notice. When
deciding between persons of equal priority, it is appropriate to choose the one
who is more involved in the patient’s care.
A close friend is defined as an adult who has exhibited special care and
concern for the patient, who is familiar with the patient’s personal values and
who is reasonably available.
b.
No Patient
Representative
If the patient is
unable to understand the notice and has no patient representative, the hospital
should follow state guidelines for
designation of a representative for healthcare decisions. It is recommended that hospitals consult
with the hospital attorneys in these situations.
B. Providing
Notification
Verbal notification to the appropriate person must
include the following information:
1.
The decision was made
by the hospital. (Not required for
Generic/ED notice)
2.
The name and
telephone number of a contact at the hospital.
3.
The beneficiary’s
rights as a hospital patient, including appeal rights.
4.
The date of the
patient's financial liability as a result of the decision. In the case of the Generic/ED notice, this
is the day after the effective date (last covered day). In the case of the Important Message, this
is the day after the planned discharge date – hospitals should indicate the
planned discharge date as well as the date of liability.
5.
The rights to QIO
review, deadlines for filing and the effect on the patient's financial
liability, and steps to file an appeal.
6.
NHCQF's toll-free
telephone number.
7.
Direction to the
1-800-MEDICARE number for additional assistance to the representative in
further explaining and filing the appeal.
It is recommended that documentation of verbal
notification, including QIO appeal rights and telephone number and the
individual’s understanding of the notice, be present in the medical record
and/or on the acknowledgment
receipt.
1.
Verbal Notification In Person
a. Acknowledgment
of Receipt of Notice
When the notice is issued in person, the signature
of the recipient and date must be documented.
For admission notices, a separate acknowledgment form must be used. The hospital must document the date and time
of receipt of any admission notice of non-coverage. The hospital should obtain an acknowledgment of receipt indicating
date and time of receipt signed by the appropriate person. A copy of the signed acknowledgment should
be provided to NHCQF along with the copy of any admission type notices being
mailed to NHCQF. The hospital should
also keep a copy of the signed acknowledgment in the hospital files.
For the Generic/ED
notice, there is an acknowledgment section on page 2 of the notice.
For the Important
Message, the acknowledgment section is at the bottom of page 1. Hospitals must also obtain documentation of
receipt of the followup copy of the Important Message. The patient/representative may initial and
date the Important Message or may sign and date a discharge checklist that
includes wording about receipt of the Important Message. The hospital may choose to deliver a new
copy of the Important Message; in this case the hospital must again obtain the
recipient’s full signature and date.
b. Refusal to
Sign Acknowledgment
If the appropriate person refuses to sign the
acknowledgment, the hospital must immediately document on the hospital
notice/Important Message the refusal to sign.
The hospital representative must sign and date the annotation indicating
the refusal. It is advisable in these
situations to have another hospital representative witness the refusal and also
sign and date the annotation. The date
of the refusal is the date of receipt of the notice/Important Message. The documentation of the refusal to sign the
acknowledgment should be included on any copies provided to NHCQF
2.
Verbal Notification
by Telephone
If the patient is incapable of understanding the
notice/Important Message and the patient representative is not available in the
hospital (i.e., the hospital cannot provide verbal and written notice in
person), the hospital must attempt to contact the patient representative by
telephone and mail the notice of non-coverage/Important Message on the same
day.
If the hospital reaches the patient representative
by telephone and provides the required verbal notification and the hospital
notice/Important Message is postmarked that same day, the date of the verbal
notification and the postmark date of the written notification is considered
the date of receipt of the notice/Important Message. If telephone "verbal" notification is made, but the
written notification is postmarked after the date of the telephone
notification, the postmark date will be considered the date of receipt of the
notice/Important Message. If telephone
"verbal" notification is made on a Saturday, Sunday or federal
holiday when the post office is closed and the notice/Important Message is
postmarked on the next working day for the post office, the notice/Important
Message issue date is considered to be the date verbal notification was
given.
3.
Unable to Establish Telephone Contact/Notification by
Certified Mail
If, after a reasonable effort, the hospital cannot
make direct telephone contact with the patient representative, the hospital
must document the unsuccessful attempt on the notice to be sent to the patient
representative and NHCQF. Messages
left on answering machines are not acceptable verbal notification. The hospital must then send the
notice/Important Message to the patient representative by certified mail,
return receipt requested. The date that
someone at the address of the representative signs (or refuses to sign) the
receipt, is considered the date of receipt of the notice/Important Message.
The patient’s liability will begin as follows:
|
Notice Type
|
Setting
|
Liability
|
|
Admission
Types
|
All
hospital settings
|
Day
after notice received
|
|
Important
Message
|
Acute
care hospital setting
|
Day
after notice received Note: The
Important Message is not a liability notice, the hospital must issue HINN #12
to transfer liability
|
|
Generic/ED
Notice*
|
Skilled
Swing bed setting
|
Third
day after notice received or day after the effective date, whichever is later
|
When a notice/Important
Message sent certified mail with return receipt requested is returned to the
hospital with no indication of a refusal or receipt date, the hospital should determine
the recipient’s receipt of notice/Important Message to be the second working
day after the hospital’s mailing date (as postmarked by the postal service).
The hospital should keep all documentation
regarding the notification and mailing process in the hospital files.</