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QIO TRANSMITTAL SERIES ISSUE: Hospital Issued Notices of Non-Coverage and QIO
Review NOTE: Effective July 2, 2007, hospitals are
required to issue a revised Important Message/Notice of Hospital Discharge
Appeal Rights to all Medicare patients within 2 calendar days of admission or
7 calendar days prior to admission.
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
explaining the reasons why Medicare covered services should end. These notices, instructions for their use
and related CMS Manual Guidelines can be found at CMS’s Beneficiary Notice Initiative
(BNI) website, http://www.cms.hhs.gov/bni/. NHCQF is in the
process of updating this transmittal to reflect these changes. In the meantime, hospitals should
disregard any information in this transmittal related to continued stay notices
and should reference the BNI site for official guidelines. This transmittal
applies to the following hospital settings: Acute Care Hospital Settings:
·
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 The hospital’s notice
of non-coverage is not considered an official Medicare coverage decision;
hospitals are not delegated the authority to determine whether or not
Medicare will pay a claim. The
purpose of the hospital notice is to give the patient knowledge for liability
purposes that in the hospital’s opinion the services are not covered under
the Medicare program and to advise the patient of appeals rights. In most cases, the
hospital is not required to issue a notice of non-coverage when it does not
plan to bill the patient. However,
hospitals with SNF swing beds should be aware that the generic/ED notice must
be provided to all patients whose skilled services are being terminated. Hospitals with swing beds must also notify
patients when they are transferring from an acute care bed to a skilled level
of care swing bed and will be using their SNF benefits. 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
generic/ED 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 provider community. TABLE OF CONTENTS: Notice of Non-Coverage Instructions Types of Notices, Time of Issuance, Patient
Liability and Grace Days Requirements for Issuing a Notice of
Non-coverage Amendments/Corrections/Rescissions/"Deemed"
Admissions/Reinstatements Skilled Level of Care in Hospitals
without SNF Swing Beds Skilled Level of Care in Hospitals with
SNF Swing Beds Patient
Request for QIO Review (Appeal) Reconsideration
of Notice Review Determinations Submission of Bill
NHCQF Review Responsibilities
Summary
Chart for Issuing Notices Types of Notices, Time of
Issuance, Patient Liability and Grace Days Click
here to access Listing of Notices
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. Continued
Stay Notices
A
continued stay notice may be issued at any time during the patient's
stay. In order for a hospital to
issue a continued stay notice of non-coverage, the hospital must determine
that the admission is covered. The
hospital may issue a continued stay notice of non-coverage if it determines
that the patient no longer requires inpatient hospital care. The hospital may issue a continued stay
notice for the following situations:
NOTE:
In cases where the patient requires a SNF level of care, the hospital does
not issue a continued stay notice if a SNF or SNF swing bed is not
available. Medicare pays the
hospital, in cost outlier cases, for the days awaiting placement until a SNF
bed/SNF swing bed is available, and the medical record documentation
indicates that SNF placement is actively being sought. See
Skilled Level of Care in Hospitals without Swing Beds.
NOTE: The hospital must issue a notice when the patient
will begin to receive skilled services in a SNF swing bed and will be
utilizing SNF benefit days. See Skilled Level of Care in Hospitals
with SNF Swing Beds. Medicare
regulations mandate the provision of two grace days to all Medicare
beneficiaries receiving continued stay notices of non-coverage except as
noted below. The hospital or the
patient cannot waive the grace days.
Therefore, when a continued stay notice is issued, the patient’s
liability does not begin until the third day after the date of effective
issuance of the notice. For example,
if the notice is issued on a Tuesday, liability would begin on Friday. Grace
days cannot be provided to Medicare beneficiaries in the following instances: 1.
The patient has
been in a covered status during a stay in a non-DRG reimbursed hospital
(psychiatric, acute rehabilitation or CAH) and a notice of non-coverage is
issued because the patient no longer requires acute or skilled nursing level
of care. 2.
A hospital has
swing beds and the patient is being "transferred" to a swing bed at
SNF level of care (the notice in this case is to indicate a change in patient
status rather than non-coverage). 3.
A hospital has
swing beds, the patient no longer requires an acute level of care and the
plan for the patient's continued care is to provide NF/ICF level care in the
swing bed. In these situations
where grace days cannot be provided, the patient’s liability (or change in
status) begins on the day after the notice is effectively served/issued. Generic/Expedited
Determination (ED) Notices When skilled services
for patients in SNF swing beds are going to be terminated, a generic/ED
notice 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. Requirements
for Issuing a Notice of Non-coverage I.
Concurrence
A.
When physician concurrence is required to issue a
notice C.
Attending physician does not give concurrence II.
Issuing the Notice
A.
Issuing the Notice to the Appropriate Person 1.
Patient understands 2.
Patient doesn’t understand a.
Patient
representative b.
No patient
representative 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
A.
Requirement
for Concurrence The
hospital must have the attending physician's concurrence written by the
physician in the medical record in order to issue a continued stay notice
of non-coverage. Concurrence is
required for all situations where a continued stay notice is being issued
including acute to SNF swing bed, refusal of SNF bed or SNF bed search, and
acute to ICF/NF swing bed. The
hospital may issue preadmission, admission, late admission
notices and 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. Acceptable Concurrence Acceptable concurrence
must be written in the medical record (orders
or progress notes) and signed and dated by the physician. The
written concurrence should specifically indicate that the patient no longer
requires hospital level of care. The concurrence must
indicate that the patient is ready, on that date, for transfer to a specified
non-acute level of care. Please note
the following clarifications regarding appropriate concurrence: ·
Examples of specified non-acute level of
care: o SNF (for acute to SNF, SNF refusal notices) o Intermediate, o Level II, o Nursing Facility (NF) Level, o Assisted Living Facility o Group home ·
Awaiting SNF/NF/ICF
transfer/placement" is not acceptable concurrence because it does not
state that the patient is currently ready for transfer and may be interpreted
as indicating that the patient will be, at some point in the future, ready
for transfer. ·
Telephone orders
used as written physician concurrence must be signed and dated by the
physician and are not considered in effect until they have been signed and
dated. The current signature and date
indicate that the physician has re-examined the patient and assessed the
patient's current level of care. ·
Verbal physician
concurrence orders (given when the attending physician is at the bedside) are
acceptable as concurrence as long as the physician signs the order before the
notice is issued. ·
Lack of acute care
orders does not constitute written concurrence. ·
The use of a rubber
stamp for written physician concurrence is acceptable provided the wording is
appropriate and the physician signs and dates the stamp. It is recommended, but not required, that
the planned phrase be pre-approved by NHCQF. C.
Attending
Physician Does Not Give Concurrence to Issue a Continued Stay Notice
A
hospital may request NHCQF to review a patient's medical record to determine
if a continued stay notice of non coverage would be appropriate if:
To
initiate QIO review the hospital must:
NHCQF
will complete the review within two working 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, the hospital
representative who completed the referral form is responsible for:
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 transfer liability to
the patient, the notice must be appropriately issued. Appropriate notifications are considered to have
been made when the notice 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). The following
guidelines must be followed for deciding whom to issue the notice to: 1. Patient Can Understand Notice
The medical record must provide documentation
that the patient is able to understand the meaning of the notice of
non-coverage, the financial ramifications and the appeals mechanism. If this is the case, the notice 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 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 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 as described in this section. Except for the generic/ED notice, the
notice should be addressed to the person who is receiving the notice. After
the notice has been issued to a patient, if the patient requests that an
extra copy of the notice 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
If
the patient is not able to understand the meaning of the notice of
non-coverage, the hospital must issue the notice 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. If the medical record indicates questionable cognitive loss, memory
deficits and/or impaired decision making skills, the provider must determine
that a patient is or is not able to comprehend its impact. 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 or Generic/ED notice. a.
Choosing
a Patient Representative
The
usual order of priority in choosing a representative is:
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. If the patient is unable to understand the notice
and has no patient representative, the hospital should attempt to explain the
notice to the patient, provide a copy of the notice to the hospital
administrator, retain a copy of the notice in the patient's medical record
and document the situation in the medical record and/or on the notice. B. Providing Notification
Verbal
notification to the appropriate person must include the following
information:
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. The
hospital must forward a copy of all notices issued to the NHCQF office within
three working days of issuance.
However, the hospital is not required to routinely send copies of
generic/ED notices to NHCQF, unless specifically requested for an expedited
appeal. The hospital must also keep a
copy of all notices issued (including acknowledgment of receipt forms and
certified delivery receipts) in the hospital files. 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 on
the acknowledgment of receipt form.
For all notices, a separate acknowledgment form must be used, except
for the generic/ED notice, which has an acknowledgment section on page 2 of
the notice. The
hospital must document the date and time of receipt of the notice of
non-coverage. The hospital should
obtain an acknowledgment of receipt indicating date and time of receipt
signed by the appropriate person. The
hospital must include a copy of this signed acknowledgment with the copy of
the hospital notice being mailed to NHCQF.
The hospital should also keep a copy of the signed acknowledgment in
the hospital files. b.
Refusal to Sign Acknowledgment
If
the appropriate person refuses to sign the acknowledgment, the hospital must
immediately document on the hospital notice 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. The copy of
the notice provided to NHCQF must have the documentation of the refusal to
sign the acknowledgment included on it. 2.
Verbal
Notification by Telephone
If
the patient is incapable of understanding the notice 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 on the same day. If
the hospital reaches the patient representative by telephone and provides the
required verbal notification and the hospital notice 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. 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. If
telephone "verbal" notification is made on a Saturday, Sunday or
federal holiday when the post office is closed and the notice is postmarked
on the next working day for the post office, the notice 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 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. When
the notice is being mailed to the patient representative and the
representative’s signature is thus not available, the unsigned acknowledgment
with the upper section completed should be mailed to NHCQF with a copy of the
notice. For generic/ED notices, documentation
below the blank recipient line indicating that the notice was mailed by
certified mail is acceptable. When
the hospital has received the signed (certified mail) receipt or a return
receipt indicating refusal of the letter, a copy should be forwarded to the
NHCQF with a copy of the actual hospital notice issued (does not apply to
generic/ED notices). The
patient’s liability will begin as follows:
When
a notice 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 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. As
an option, while awaiting the return receipt, in an attempt to establish
notification and transfer of liability as soon as possible, the hospital may,
but is not required to, continue to attempt to reach the patient
representative by telephone or in person.
Once verbal notification is provided, the hospital must then provide
in person or by mail (postmarked the same day) a redated notice indicating
the patient's actual date of liability.
This notification would then supersede the notice mailed without prior
verbal contact. * Please note: For Generic/ED notices issued by certified
mail, the effective date (last Medicare covered day) must remain as the last
date that the patient receives Medicare covered care. This date must be recorded on the notice.
Therefore, a note in the additional information section is recommended to
advise the patient representative of the liability date. Place an asterisk next to the effective
date on page 1 and in the “Additional Information (optional)” space on page 2,
insert the following message: “*Although the
last Medicare covered day will be as indicated on the first page of this
notice, the patient will become liable for any continued noncovered services
on the third day after this notice is received by certified mail.” Amendments/Corrections/Rescissions/"Deemed"
Admissions/Reinstatements Issuing a notice of
non-coverage does not relieve the hospital or attending physician of the
responsibility for monitoring the patient’s condition and making level of care
changes or appropriate discharge planning. NHCQF recommends that
hospitals advise patients (or, when patients are unable to comprehend,
patient representatives) in writing of a change in the patient's coverage
after a notice of non-coverage has been issued. As with notices of non-coverage, these notices are not
considered official Medicare coverage decisions; hospitals are not delegated
the authority to determine whether or not Medicare will pay a claim. The purpose of these notices is to give
the patient knowledge for liability purposes that, in the hospital's opinion,
the services are covered by Medicare.
Please note that a copy of these notices (except amended generic/ED
notices) should be forwarded to NHCQF. Amending
Generic/ED Notice
If the hospital
decides to provide extra days of care, or shortens the time frame (in
situations where more than two days prior notice was given) to decrease the
number of days of care in the covered period, and the initial generic/ED
notice has already been validly delivered with a different coverage end date,
the provider may amend the notice.
Notify the patient of the new effective date/coverage end date and
amend the original notice with the new date.
Provide a copy of the amended notice to the patient. If an appeal has
been requested, the hospital must immediately notify the QIO that the
original notice has been amended, and send a copy of the amended notice to
the QIO as soon as possible. Correcting
HINNs
If
the hospital has determined that it has issued a HINN with incorrect
information in the notice, the hospital may issue a corrected notice. If the hospital indicated the liability to
start too soon, the hospital should correct the notice, notify the patient and
provide a corrected copy of the notice to the patient and to the QIO. Because
HINNs are issued within one to three days prior to the patient liability,
there usually is not an instance where a hospital will want or will be
allowed to shorten the days before the liability will begin. For example, if the notice is given with
two grace days, the hospital cannot shorten the time before liability would
begin on the third day. However,
if the hospital issued a notice in a situation where liability should begin
the next day, but by mistake gave the patient two grace days, the hospital
can correct the notice to shorten the span before liability will begin. The
hospital may correct a HINN in situations where the hospital has determined
that the wrong notice type was issued.
For example, an admission type notice was issued but the admission was
medically necessary and the hospital meant to give a continued stay
notice. The hospital must notify the
patient of the error and provide a copy of the correct notice to the patient
and to the QIO. If an appeal has been
requested, the hospital must immediately notify the QIO that the original
notice was corrected. Note:
at the time of the corrected notice, the patient must receive appropriate
appeal rights and cannot be held liable for days that have gone by. | |||||||||||||||||||
