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The QIO for Maine, New Hampshire and Vermont |
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QIO TRANSMITTAL SERIES ISSUE: Model Hospital Notices - Printable
pages MODEL
HOSPITAL NOTICES OF MEDICARE NONCOVERAGE
Note: Notices numbered 02, 04, 05, 07, 09, 10,
12, 13, 22 and 23 are no longer used.
Effective July 2,
2007, notices number 14-21, 24 and 25 are no longer used. Effective July 2, 2007, the Important Message
from Medicare and the Detailed Notice of Discharge are to be used by all
inpatient hospitals. These notices
and instructions for their use can be found at Medicare’s Beneficiary
Notice Initiative web site, http://www.cms.hhs.gov/bni/. The following table
summarizes the notice types provided in this QIO Transmittal Series 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/.
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, and the Important Message and Detailed
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. 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. 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
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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ACKNOWLEDGEMENT OF
RECEIPT OF NOTICE 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) 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 services or condition)
because: ___ 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:
·
If you decide to
go ahead with the hospitalization, you will have to pay for customary charges
for all services furnished during the stay, except for those services for
which you are eligible under Part B. |
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HIN-03 Page
2 If you want an immediate review of your case:
QIO Contact Information: Northeast Health Care Quality Foundation (NHCQF) 15 Old Rollinsford Road, Suite 302 Dover, New Hampshire 03820-2830 800-772-0151 If you do not want an immediate review:
Results of the QIO Review:
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. _____________________________________________________________________________________ |
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HIN-06 ADMISSION
NOTICE TO ACUTE CARE BED Page
1 Verbal
Notification Provided (Hospital Letterhead) 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 services or condition)
because: ___ 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:
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HIN-06 Page
2 If you want an immediate review of your case:
QIO Contact Information: Northeast Health Care Quality Foundation (NHCQF) 15 Old Rollinsford Road, Suite 302 Dover, New Hampshire 03820-2830 800-772-0151 If you do not want an immediate review:
Results of the QIO Review:
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. _____________________________________________________________________________________ |
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HIN-08 LATE
ADMISSION NOTICE TO ACUTE CARE BED Page
1 Verbal
Notification Provided (Hospital Letterhead) 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 services or condition)
because: ___ 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:
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HINN-08 Page
2 If you want an immediate review of your case:
QIO Contact Information: Northeast Health Care Quality Foundation (NHCQF) 15 Old Rollinsford Road, Suite 302 Dover, New Hampshire 03820-2830 800-772-0151 If you do not want an immediate review:
Results of the QIO Review:
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. _____________________________________________________________________________________ |
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HIN-11 ADMISSION/LATE
ADMISSION NOTICE TO ACUTE CARE BED Page
1 Certified
Mail (Hospital Letterhead) Name of
Patient:___________________ Name
of Physician:_______________________ Patient
ID Number: _________________ Date
Issued: ____________________________ _________________________________________________________________________________ We
believe that Medicare is not likely to pay for the patient’s admission
for (specify services or
condition) because: ___ 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:
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HINN-11 Page
2 If you want an immediate review of this case:
QIO Contact Information: Northeast Health Care Quality Foundation (NHCQF) 15 Old Rollinsford Road, Suite 302 Dover, New Hampshire 03820-2830 800-772-0151 If you do not want an immediate review:
Results of the QIO Review:
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. _____________________________________________________________________________________
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HIN
- 26 DEEMED
ADMISSION LETTER AFTER ADMISSION NOTICE (Hospital Letterhead) Date
of Notice: Patient/Patient
Representative Address RE: Name of Patient: Medicare Number: Admission Date: Attending Physician: Dear
(Patient/Patient Representative): | ||||||||||||||||||||||||||||
