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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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NHCQF MODEL LETTERS FOR HOSPITAL NOTICES OF MEDICARE
NONCOVERAGE
Printable
pages
CMS’s Beneficiary Notice Initiative web site is the
official site for the CMS forms and model language. CMS forms are standardized notices that may not be changed. Notices with model language may be altered
as long as the required information is retained. It is recommended that hospitals use the model language to avoid
questions of invalid notices.
The following CMS notices should be accessed
through the BNI web site (www.cms.hhs.gov/BNI/):
CMS Notice
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Description
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HINN
#12
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Model language for
notice to be used in association with the Hospital Discharge Appeal Notices
(Important Message) to inform Medicare beneficiaries of their potential
liability for a noncovered continued stay
**Use
in interim until CMS develops ABN form for hospital inpatients
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Important
Message
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CMS-R-193. Notice to be used for hospital Medicare
inpatients to describe hospital discharge appeal rights.
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Detailed
Notice of Discharge
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CMS10066. Notice
to be used when patient requests QIO appeal of discharge plan. Provides space for detailed explanation of
why inpatient hospital services should end and applicable Medicare
regulations and policies.
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Expedited
Determination Notice
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CMS10123. Notice to be used in hospitals with SNF
swing beds to notify patients of appeal rights associated with the termination
of Medicare covered services.
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Expedited
Determination Detailed Notice
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CMS10124. Notice
to be used when patient requests QIO appeal of termination of SNF
services. Provides space for detailed
explanation of why SNF services should end and applicable Medicare
regulations and policies.
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NHCQF appeal contact information to be inserted in
the CMS standardized notices is:
Northeast Health Care Quality Foundation
1-800-772-0151
NHCQF has developed additional and more specific
model language for some of the CMS notices.
The NHCQF model language conforms to the CMS model language and includes
the appeal contact information for NHCQF.
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.
The following is a description of the NHCQF model
letters found in this transmittal.
Asterisked notes identify the associated CMS model letters, if
applicable.
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.
Admission/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 (NHCQF #32)
32 Notice to
Beneficiary of QIO Review of Need for Continued Hospitalization**
*CMS Preadmission/Admission HINN – Model language for
preadmission, admission, late admission notices and acknowledgment
**CMS HINN #10
– Model language for hospital requested QIO review and acknowledgment
NHCQF-01 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.
NHCQF-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:
·
You should talk to
your doctor about this notice and any further health care you may need.
·
You also have the
right to an appeal, that is, an immediate review of your case by a Quality
Improvement Organization (QIO). The QIO
is an outside reviewer hired by Medicare to make a formal decision about
whether your admission is covered by Medicare.
See page 2 for instructions on how to request a review and contact
the QIO.
·
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.
NHCQF-03
Page 2
If you want an immediate review of your case:
·
Call the QIO
immediately at the number listed below, but no later than 3 calendar days after
you receive this notice. If you are
admitted, you may call the QIO at any point in the stay.
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:
·
You may still request
a review within 30 calendar days from the date of receipt of this notice by
calling the QIO at the number above.
Results of the QIO Review:
·
The QIO will send you
a formal decision about whether your hospitalization is appropriate according
to Medicare’s rules, and will tell you about your reconsideration and appeal
rights.
- IF
THE QIO FINDS YOUR HOSPITAL CARE IS COVERED, you will be refunded any
money you may have paid the hospital except for any applicable copays,
deductibles, and convenience items or services normally not covered by
Medicare.
- IF
THE QIO FINDS THAT YOUR HOSPITAL CARE IS NOT COVERED, you are responsible
for payment for all services beginning on the day you are admitted to the
hospital.
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY:
1-877-486-2048.
_______________________________________________________________________________
NHCQF-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:
·
You should talk to
your doctor about this notice and any further health care you may need.
·
You also have the
right to an appeal, that is, an immediate review of your case by a Quality
Improvement Organization (QIO). The QIO
is an outside reviewer hired by Medicare to make a formal decision about
whether your admission is covered by Medicare.
See page 2 for instructions on how to request a review and contact
the QIO.
·
If you decide to
go ahead with the hospitalization, you will have to pay for customary charges
for all services furnished after receipt of this hospital notice, except for
those services for which you are eligible under Part B.
NHCQF-06
Page 2
If you want an immediate review of your case:
·
Call the QIO immediately
at the number listed below or you may call the QIO at any point in the stay.
·
You may also call the
QIO for quality of care issues.
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:
·
You may still request
a review within 30 calendar days from the date of receipt of this notice by
calling the QIO at the number above.
Results of the QIO Review:
·
The QIO will send you
a formal decision about whether your hospitalization is appropriate according
to Medicare’s rules, and will tell you about your reconsideration and appeal
rights.
- IF
THE QIO FINDS YOUR HOSPITAL CARE IS COVERED, you will be refunded any money
you may have paid the hospital except for any applicable copays,
deductibles, and convenience items or services normally not covered by
Medicare.
- IF
THE QIO FINDS THAT YOUR HOSPITAL CARE IS NOT COVERED, you are responsible
for payment for all services beginning on (specify date)
For more information,
call 1-800-MEDICARE (1-800-633-4227), or TTY:
1-877-486-2048.
_______________________________________________________________________________
NHCQF-08 LATE ADMISSION NOTICE TO ACUTE CARE
BED
Page 1 Verbal
Notification Provided
(Hospital Letterhead)