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QIO TRANSMITTAL SERIES ISSUE: MODEL
HOSPITAL NOTICES OF MEDICARE NONCOVERAGE
Note: Notices numbered 02, 04, 05, 07, 09, 10,
12, 13, 22 and 23 are no longer used.
The following table
summarizes the notice types by provider type. Please note that with the exception of the generic/ED
notices, these notices are to be used for patients in, or being admitted to,
acute care beds only. The generic/ED
notices are to be used for patients in SNF swing beds only. Note also that these notices are for
patients with traditional or Fee for Service Medicare. Notices for patients who belong to managed
care plans can be found at Medicare’s Beneficiary Notice Initiative web site,
http://www.cms.hhs.gov/bni/.
*These
notices are used in hospitals with swing beds only when the patient is
refusing transfer to the swing bed or when no swing beds are available in the
hospital and the patient is refusing a SNF bed search or SNF bed elsewhere. The
model notices in this transmittal address most situations in which the
hospital will be issuing a hospital notice.
However, if circumstances in any individual case vary from those for
which the models are intended, it is the hospital's responsibility to modify
the notice (with the exception of the generic/ED notice which cannot be
altered) to accommodate the particulars of the case, ensuring that the
contents and issuance of the notice are in accordance with the information
provided in this transmittal and reflected in the model notices. Hospitals may develop their own notice
formats, which may be used after approval is obtained from NHCQF. Hospital developed notices must be in
accordance with the information provided in this transmittal. For
Maine and Vermont Hospitals: Model notices #20 and #21, referencing State
certified Nursing Facility (NF)/ICF swing beds, refer to New Hampshire and
the New Hampshire Medicaid program.
These letters are written to reflect the New Hampshire Medicaid review
contract as NHCQF holds the New Hampshire Medicaid contract and works with
the Medicaid State Agency. This
situation does not exist in Acknowledgments
01 Acknowledgment
of receipt of notice when notice is given in person or mailed to the
patient representative after telephone notification was made or
attempted (any type of notice) Preadmission Notices
03 Preadmission notice for proposed
admission to any acute care bed (i.e., this letter is not applicable
for admissions to SNF or ICF/NF swing beds) Admission
Notices
06 Admission notice for admissions to any
acute care bed (i.e., this letter is not applicable for admissions to SNF
or ICF/NF swing beds), in any of the following circumstances: 1.
The patient is
being given verbal and written notice by 3:00 p.m. on the day of admission;
or 2. The patient
representative is being given verbal and written notice in person by 3:00
p.m. on the day of the patient's admission; or 3.
The patient's
representative was verbally notified by telephone by 3:00 p.m. on the day of
the patient's admission and written notice is being mailed (postmarked) the
same day. Late
Admission Notices
08 "Late" admission notice for admission to any acute
care bed (i.e., this notice is not applicable for admissions to SNF or
ICF/NF swing beds), in any of the following circumstances: 1.
The patient is
being given verbal and written notice after 3:00 p.m. on the day of
admission; or on any subsequent day of the hospital stay; or 2.
The patient's
representative is being given verbal and written notice in person after 3:00
p.m. on the day of the patient's admission; or on any subsequent day of the
hospital stay; or 3.
The patient's
representative was verbally notified by telephone after 3:00 p.m. on the day
of the patient's admission or on any subsequent day of the hospital stay and
written notice is being mailed (postmarked) the same day. Late Admission Notice by
Certified Mail 11 Admission or "late"
admission notice for admission to any acute care bed (i.e., this
notice is not applicable for admissions to SNF or ICF/NF swing beds), when
both of the following circumstances apply: 1.
The hospital has
determined that the patient is incapable of understanding the notice, and 2.
The hospital has not
established contact with the patient's representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt requested. Continued Stay Notices
14 Continued stay notice issued in a DRG
reimbursed facility when: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient representative was verbally notified by telephone and
written notice is being mailed on the same day. 15 Continued stay notice issued in a DRG
reimbursed facility when: 1.
The hospital has determined
that the patient is incapable of understanding the notice, and 2.
The hospital has not
established contact with the patient's representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt request. 16 Continued stay notice issued in a non-DRG
reimbursed facility acute care bed (i.e., this letter is not applicable
for stays in a SNF or ICF/NF swing bed) when: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 17 Continued stay notice issued in a non-DRG
reimbursed facility acute care bed (i.e., this letter is not applicable
for stays in a SNF or ICF/NF swing bed) when: 1.
The hospital has
determined that the patient is incapable of understanding the notice, and 2.
The hospital has not
established contact with the patient's representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt request. 18 Continued stay notice issued in any
facility with SNF swing beds when patient's level is changing from acute
to SNF and: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 19 Continued stay notice issued in any
facility with SNF swing beds when the patient's level is changing from acute
to SNF and: 1.
The hospital has
determined that the patient is incapable of understanding the notice, and 2.
The hospital has not
established contact with the patient's representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt request. 20 Continued stay notice issued in any
facility with ICF/NF swing beds when the patient's level is changing from acute
to ICF/NF level and: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 21 Continued stay notice issued in any
facility with ICF/NF swing beds when the patient's level is changing from acute
to ICF/NF level and: 1.
The hospital has
determined that the patient is incapable of understanding the notice, and 2.
The hospital has not
established contact with the patient's representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt request. SNF Bed/Search Refusal
24 Continued stay notice issued to a
patient in a DRG reimbursed facility* when the patient has refused a SNF bed
search or available SNF bed when: 1.
The patient is being
given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. * If patient is in a DRG reimbursed bed, two
grace days are given. However, if
patient is in a non-DRG reimbursed facility (psychiatric, rehabilitation or
CAH) no grace days are given and the model letter must be revised to reflect
this. 25 Continued stay notice issued in a DRG
reimbursed facility* when the patient representative has refused a SNF bed
search or an available SNF bed when: 1.
The hospital has
determined that the patient is incapable of understanding the notice, and 2.
The hospital has
not established contact with the patient’s representative to provide the
required verbal notification. In these instances, the written
notice must be sent by certified mail, return receipt request. * If patient is in a DRG reimbursed bed, two
grace days are given. However, if
patient is in a non-DRG reimbursed facility (psychiatric, rehabilitation or
CAH) no grace days are given and the model letter must be revised to reflect
this. Special
Notices
Hospitals are required to advise the patient/patient
representative in writing of reinstatements/deemed admissions and
rescissions. The following three (3)
models are recommended for use, but may be altered at the hospital’s
discretion. 26 Reinstatement/Deemed Admission Notice
after an admission type notice issued when the patient becomes acute level of
care after a non-covered period. 27 Reinstatement after a continued stay
notice issued when the patient reverts back to an acute level of care. 28 Rescission notice following an
inappropriately issued notice of any type. Hospital Requested QIO Concurrent
Review
29 Continued stay notice issued in a DRG
reimbursed facility when NHCQF has completed a Hospital Requested QIO
Concurrent Review and agrees that continued stay is not medically necessary
when: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 30 Continued stay notice issued in a Non-DRG
reimbursed facility and/or patient being transferred into a swing bed
when NHCQF has completed a Hospital Requested QIO Concurrent Review and
agrees that continued stay is not medically necessary when: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 31 Referral Form: Hospital Request for QIO Review/Denial 32 Notice to Beneficiary of QIO Review
of Need for Continued Hospitalization Generic/ED
Notices
33 Generic/ED Notice of Medicare Provider Non-Coverage issued
in any facility with swing beds when the patient's level is changing from SNF
to ICF/NF level or the patient is being discharged to any setting other
than acute or another SNF, and: 1.
The patient is
being given verbal and written notice; or 2.
The patient
representative is being given verbal and written notice in person; or 3.
The patient
representative was verbally notified by telephone and written notice is being
mailed on the same day. 4.
The hospital has
determined that the patient is incapable of understanding the notice, and the
hospital has not established contact with the patient's representative
to provide the required verbal notification.
In these instances, the written notice must be sent by certified
mail, return receipt request. 34 Detailed Explanation of Non-Coverage Notice issued in any
facility with swing beds when the patient has appealed the generic/ED notice. |
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HIN-01 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE Page 1 Patient _________________________________________ Patient Representative
____________________________________________ TO BE COMPLETED BY
PATIENT OR PATIENT REPRESENTATIVE
This is to acknowledge that I have
received this change in level of care / notice of noncoverage of services from the Hospital on (Date)
. I understand that my
signature below does not indicate
that I agree with the notice, only that I have received a copy of the notice. _____________________________________________ _________ __________ (Signature of Patient/Patient Representative) (Time) (Date) (If mailed, insert) Please
complete and sign this acknowledgment and return to: (Insert name and address of hospital contact
person) TO BE COMPLETED BY HOSPITAL (Optional When Providing
Notice In Person)
[ ] Patient/patient representative verbally
notified of notice on ___________ at ________ (Date) (Time) by
___________________________________. (Hospital Representative) Notice Mailed on
________________ (Date) [ ] Verbal notification
of patient/patient representative attempted on ___________ (Date) by
____________________________________; attempt unsuccessful. (Hospital Representative) Notice Mailed by Certified Mail on ________________
(Date) For Hospital Use: Optional Form For Documentation Of
Required Verbal Notification: The Patient / Patient
Representative has been informed of the following: [ ] Decision was made by
(Name of Hospital) [ ] Effective date of
change in level of care [ ] Rights to QIO review
and the effect of review on the patient’s change in level of care [ ] The
Northeast Health Care Quality Foundation toll-free and local telephone number
and mailing address. |
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HIN-03 PREADMISSION
NOTICE TO ACUTE CARE BED Page
1 Verbal
Notification Provided (Hospital Letterhead) Date
of Notice: Patient/Patient
Representative Address RE: Name of Patient: Medicare Number: Proposed Admission Date: Attending Physician: YOUR IMMEDIATE ATTENTION IS REQUIRED Dear
(Patient/Patient Representative): The
purpose of this notice is to inform you that the (Name of Hospital)
finds that the patient's proposed admission for (specify services or
condition) would not be covered under Medicare because (specify
(1): is/are not medically necessary OR (2): could be safely
rendered in another setting). This determination was
based upon the (Name of Hospital) understanding and
interpretation of available Medicare coverage policies and guidelines. You should discuss with the patient's attending
physician other arrangements for any further health care the patient may
require. If
the patient decides to be admitted to this hospital at this time, the patient
will be financially responsible for all customary charges for services
rendered during the stay, except for those services for which the patient is
eligible under Part B. This
notice, however, is not an official Medicare determination. The Northeast Health Care Quality
Foundation (NHCQF) is the Quality Improvement Organization (QIO) authorized
by the Medicare program to review inpatient hospital services provided to
Medicare patients in the States of Maine, If you disagree with our decision, you may request a review by NHCQF. |
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HIN-03 Page
2 If not admitted, you
may request a review of the facts in the case by NHCQF. If you request this review within 3
calendar days after receipt of this notice, NHCQF will perform an expedited
review and will respond to you within 2 working days after receipt of your
request. If you do not want an
expedited review, you may request, up to 30 calendar days after receipt of
this notice, a routine review by NHCQF; NHCQF will respond to you within 60
calendar days after receipt of your request for review and receipt of a copy
of this notice and the medical record. If admitted, you may
request, at any point during the hospital stay, an expedited review of the
facts in the case by NHCQF. NHCQF
will respond to you within 2 working days after receipt of your request. If already discharged, you may request,
within 30 calendar days after receipt of this notice, a routine review by
NHCQF. NHCQF will respond to you
within 60 calendar days after receipt of your request and receipt of a copy
of this notice and the medical record. Requests
for reviews by NHCQF may be made through the hospital or directly to NHCQF by
telephone or in writing to the following: Northeast Health Care Quality Foundation (NHCQF) (603) 749-1641 800-772-0151 Results of NHCQF Review: In
any case where you request a review, NHCQF will send you a formal
determination of the medical necessity and appropriateness of the patient's
hospitalization and will inform you of appeal rights (if Medicare coverage is
being denied). If NHCQF determines
that the patient did require inpatient hospital care, the patient will be
refunded any amount collected by the hospital except for payment of
deductible, coinsurance or any convenience services or items normally not
covered by Medicare. However, if
NHCQF agrees with the hospital's decision, the patient is still responsible
for payment of all services as explained in this notice. Should
you have any questions, please feel free to contact (the name of a
hospital representative or department). Sincerely, _____________________________________ (Hospital
Representative) cc: Attending Physician Northeast Health Care Quality Foundation |
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HIN-06 ADMISSION NOTICE TO ACUTE CARE BED Page
1 Verbal
Notification Provided (Hospital Letterhead) Date
of Notice: Patient/Patient
Representative Address RE: Name of Patient: Medicare Number: Admission Date: Attending Physician: YOUR IMMEDIATE ATTENTION IS REQUIRED Dear
(Patient/Patient Representative): The
purpose of this notice is to inform you that the (Name of Hospital)
finds that the patient's admission for (specify services or condition)
is not covered under Medicare because (specify services to be rendered
or condition to be treated) (specify (1): is/are
not medically necessary OR (2): could be safely rendered
in another setting). This
determination was based upon the (Name of Hospital)
understanding and interpretation of available Medicare coverage policies and
guidelines. You should discuss with
the patient's attending physician other arrangements for any further health
care the patient may require. If
the patient decides to remain in the hospital, the patient will be
financially responsible for all customary charges for all services rendered
after receipt of this notice, except for those services for which the patient
is eligible under Part B. | ||||||||||||||||||||||||||||||||||||
