I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 1 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2) any other entity or organization in which Tenet Healthcare Corporation or an Affiliate owns a direct or indirect equity interest greater than 50%; and (3) any hospitals or healthcare facility in which an Affiliate either manages or controls the day-to-day operations of the facility provide inpatient care to Medicare beneficiaries (each, a Tenet Hospital ) 1 (collectively, Tenet ). II. PURPOSE: The purpose of this policy is to describe the circumstances in which Tenet Hospitals must issue the following notices to Medicare beneficiaries regarding inpatient coverage issues: Important Message from Medicare (IMFM), Hospital-Issued Notice of Noncoverage (HINN), Hospital Request for Review (HRR) - by Quality Improvement Organization (QIO), and Detailed Notice of Discharge. The purpose of these beneficiary notices is to enable the beneficiary or representative to better participate in decisions affecting his or her care and financial liability. III. DEFINITIONS: A. For the purposes of this policy, Physician means a physician or other licensed independent practitioner who has been granted admitting privileges by the Tenet Hospital s medical staff and is legally accountable for establishing a patient s diagnosis. B. Physician Order means an order from the Physician admitting the patient to the Tenet Hospital or the Physician responsible for the patient s general medical management during the admission. The order may be electronic, in writing, or be a telephone/verbal order as allowed by the Tenet Hospital s medical staff bylaws. C. Case Management means a collaborative process of assessment, planning, facilitation, care coordination and advocacy for options and services to meet an individual s health needs through communication and available resources to promote quality, cost- effective outcomes. D. Inpatient means any person who has been admitted to a Tenet Hospital for bed occupancy for purposes of receiving hospital services. E. Outpatient means a person who has not been admitted by the Tenet Hospital as an Inpatient but is registered on the Tenet Hospital records as an Outpatient and receives services from the Tenet Hospital. The duration of services and time of 1 This policy is Medicare-specific. It is not applicable to Medicaid recipients unless they are also Medicare beneficiaries.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 2 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 day are not determinative of Outpatient Status. Observation Services are considered an Outpatient level of care. F. Patient Status means Inpatient or Outpatient. G. Observation Services or Observation means assessment, short-term treatment, reassessment, and stabilization before decision to admit to Inpatient or discharge. H. INTERQUAL or other Tenet approved clinical screening criteria mean clinical decision support guidelines licensed for use by hospitals and managed care companies to evaluate the appropriateness of medical interventions and level of care based on clinical criteria and standards I. Secondary Physician Review means a clinical review performed by a physician on the Utilization Management Committee other than the ordering physician when INTERQUAL or other Tenet approved clinical screening criteria guidelines suggest a different Patient Status or Level of Care than that ordered. J. Hospital Case Manager means, for the purpose of this policy, a Tenet Hospital representative appropriately educated in the accurate application of INTERQUAL or other Tenet approved clinical screening criteria. The Hospital Case Manager may be a Tenet Hospital employee or a contractor. K. Federal health care program means any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government, including, but not limited to, Medicare, Medicaid/Medi-Cal, managed Medicare/Medicaid/Medi- Cal, TriCare/VA/CHAMPUS, SCHIP, Federal Employees Health Benefit Plan, Indian Health Services, Health Services for Peace Corp Volunteers, Railroad Retirement Benefits, Black Lung Program, Services Provided to Federal Prisoners, Pre- Existing Condition Insurance Plans (PCIPs) and Section 1011 Requests. IV. POLICY: A. Important Message from Medicare (IMFM) The IMFM is a standardized written notice of beneficiary appeal rights regarding coverage decisions made during a hospital stay. 1. The IMFM notice must be given to all beneficiaries in original Medicare fee-for-service program and to those in Medicare Advantage (MA) and other Medicare health plans subject to the MA regulations.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 3 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 2. The Tenet Hospital must provide the IMFM to the beneficiary: a. Within two days of admission (this is known as the admission/initial IMFM ); and b. Not more than two calendar days before the day of discharge. (This is known as the Follow-up Notice.) A Follow-up Notice is not required if delivery of the admission IMFM falls within two calendar days of discharge; if the beneficiary is being transferred from one inpatient hospital setting to another inpatient hospital setting; or when a beneficiary exhausts Part A hospital days. 3. If the beneficiary is considered by the Tenet Hospital to be incapable of receiving or understanding the IMFM or Follow-up Notice, the Tenet Hospital must provide the notices to a beneficiary representative. 2 4. The Tenet Hospital must obtain the signature of the beneficiary (or his/ her representative) on a copy of the IMFM and Follow-up Notice(s), and must retain the signed copies in the beneficiary s medical record. B. Detailed Notice of Discharge (Detailed Notice) When a Tenet Hospital is notified by the QIO that a beneficiary has requested expedited review of a discharge determination, the Tenet Hospital must deliver a Detailed Notice (CMS-10066) to the beneficiary and QIO as soon as possible, but not later than noon of the day after receiving notice from the QIO. The Tenet Hospital must also provide the medical record and any information the QIO requires to make the expedited determination; this information must be provided in writing or by telephone, as requested by the QIO, and it must be provided no later than noon of the day after the information was requested. C. Hospital Notices Regarding Coverage Determinations 1. Tenet Hospitals must also issue certain additional notices regarding coverage determinations to Medicare beneficiaries in the Medicare feefor-service program. The type of notice to be issued and the effect of the notice upon beneficiary financial liability depend on the timing of the determination and the basis upon which the lack of medical necessity or appropriateness of level of care has been determined. 3 2 Tenet Hospitals must have in place, and adhere to, appropriate State-specific processes for identifying when a beneficiary requires the assistance of a representative and who may act in that capacity. 3 This policy sets forth the minimum standards for Tenet Hospitals. To the extent that local QIO instructions require more or different procedures, those QIO instructions must also be followed. In the event that a Tenet Hospital identifies a conflict between this policy and local QIO instructions, the Tenet Hospital should notify its Regional Counsel immediately.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: V. PROCEDURES: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 4 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 a. HINN generally a HINN must be issued to a Medicare fee-forservice beneficiary when the Tenet Hospital determines that the inpatient services the Medicare beneficiary is receiving (or about to receive) will not be covered by the Medicare program because based on national coverage policy 4 or Local Coverage Determination (LCD) 5 the services are (a) not medically necessary; (b) not being delivered in the most appropriate setting; or (c) are custodial in nature. The HINN informs the beneficiary (a) when the beneficiary s financial responsibility for services will begin, and (b) how to appeal this hospital utilization review determination. A HINN may be issued prior to admission, at admission, or at any point during an inpatient stay when the Tenet Hospital makes the utilization determination. b. HRR Notice a Tenet Hospital must issue an HRR to a Medicare fee-for-service beneficiary whenever the Tenet Hospital requests QIO review of a discharge decision with which the beneficiary s attending physician does not concur. A. Issuance of Admission IMFMs and Follow-Up Notices 1. Admission IMFM a. The Tenet Hospital must designate individuals who must issue an admission IMFM to all beneficiaries enrolled in Medicare fee-forservice, MA plans, and other Medicare health plans subject to the MA regulations who are admitted as inpatients, including those admitted as inpatients after receiving outpatient observation services. 6 b. The admission IMFM must be given to the beneficiary as soon as possible within two (2) calendar days of admission, or at preadmission, but not more than seven (7) calendar days before admission. 4 National Coverage Determinations can be found at the Centers for Medicare and Medicaid Services (CMS) coverage Web site at: http://www.cms.gov/center/coverage.asp. Occasionally, national Medicare coverage policy is issued through service-specific regulations. This policy applies in either situation. 5 LCDs are formulated by MACS and intermediaries, which should be contacted for further information. 6 This function might be performed by the House Supervisor, Charge Nurses, Patient Access, Case Management staff, Nursing Supervisor and/or Director of Clinical Quality Improvement (DCQI) as assigned and designated by the Tenet Hospital.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 5 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 c. The Tenet Hospital must designate individuals who must review the admission IMFM with the beneficiary and have the beneficiary sign and date the admission/initial IMFM to confirm receipt. The beneficiary must be given the original IMFM notice, and the Tenet Hospital must retain the signed copy in the beneficiary s medical record. 2. Follow-Up Notice a. The Tenet Hospital must designate individuals who issue the Follow-Up Notice to all beneficiaries enrolled in Medicare fee-forservice, MA plans, and other Medicare health plans subject to the MA regulations. 7 b. The Follow-Up Notice must be given to the beneficiary as soon as possible before discharge, but no more than two (2) calendar days before the day of discharge. 8 c. The Follow-up Notice may be delivered on the day of discharge, but only when unavoidable; this must not become the Tenet Hospital s routine practice. Once a Follow-Up Notice has been given, the Tenet Hospital must allow at least four (4) hours before discharging the beneficiary to allow the beneficiary to consider his or her rights. d. The Tenet Hospital must designate individuals who must review the Follow-Up Notice with, and have the beneficiary sign and date a copy of the Follow-Up Notice to confirm receipt. The beneficiary must be given the Follow-Up Notice and the Tenet Hospital must retain the signed copy in the medical record. The original document is to be given to the beneficiary. 3. Beneficiary Refusal to Sign If the beneficiary refuses to sign the IMFM or Follow-up Notice, the Tenet Hospital must designate individuals who must note the refusal and date of refusal on the notice form, 9 sign and date the notation and have the refusal witnessed by a second Tenet Hospital employee. The witness must sign 7 This function might be performed by the House Supervisor, Charge Nurses, Patient Access, Case Management staff, Nursing Supervisor and/or DCQI as assigned and designated by the Tenet Hospital. 8 If the beneficiary s status changes after the issuance of a Follow-up Notice so that the discharge falls beyond the two-day timeframe, the Tenet Hospital must deliver another copy of the Follow-up Notice within two calendar days of the new planned discharge date. It cannot be routinely given on pre-scheduled days i.e., Monday, Wednesday, Friday. 9 Under these circumstances, the date of refusal will be considered the date of the notice.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 6 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 and date a copy of the notice with the notation regarding the refusal for the beneficiary s medical record. The original document is to be given to the beneficiary. 4. Notice Delivery to Beneficiary Representatives a. When Tenet Hospital s designated individuals believe that a beneficiary is unable to read or understand the IMFM or Follow- Up Notice, the Tenet Hospital must deliver the IMFM or Follow- Up Notice to the beneficiary s authorized representative, and have the representative sign and date a copy of the notice. 10 b. If the Tenet Hospital is unable to deliver the notice to the beneficiary s representative personally, the Tenet Hospital s designated individuals must telephone the beneficiary s representative to advise him or her of the beneficiary s rights, including the right to appeal discharge decisions as discussed in the IMFM and Follow-Up Notices. If the representative agrees during a telephone call, a notice may be e-mailed to the representative. 11. All telephone documentation must be signed, dated and witnessed by two employees. c. If the representative is not available for in-person or live telephone delivery (voicemail messages are not sufficient), the Tenet Hospital s designated individuals must forward the IMFM or Follow-Up Notice the same day by certified mail or fax to the representative. All such electronic transmissions must meet Tenet s information privacy and security policies and standards. 5. Medical Record Documentation a. The Tenet Hospital s designated individuals must place a copy of the IMFM and Follow-Up Notices signed and dated by the beneficiary or beneficiary s representative in the beneficiary s medical record. In the case of a beneficiary s refusal to sign, a copy of the notice noting the refusal and witnessed (signed and dated) by a second Tenet Hospital employee must be placed in the beneficiary s medical record. The original document is to be given to the beneficiary. 10 This function might be performed by the House Supervisor, Charge Nurses, Patient Access, Case Management staff, Nursing Supervisor and/or DCQI as assigned and designated by the Tenet Hospital. 11 Under these circumstances, the date of the telephone notice, fax, or certified letter will be considered the date of the notice.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 7 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 b. The Tenet Hospital s designated individuals must also document in the beneficiary s medical record all attempted contacts with beneficiary representatives, including telephone calls, messages, faxes, e-mails and certified mail. 6. Beneficiary Appeal Rights: Hospital Responsibilities a. A beneficiary who disagrees with the Tenet Hospital determination that inpatient care is no longer necessary has the right to request an expedited review of that determination by the QIO. 12 b. If the beneficiary refuses discharge or requests the expedited QIO review process, the individual receiving this information must immediately contact the Case Management Department. c. The beneficiary must not be discharged if he or she requests expedited QIO review in writing or by telephone until the QIO determination has been made. d. If the beneficiary or beneficiary s representative refuses discharge and does not seek QIO review, follow Section IV.B.6.c.(2) below. B. Issuance of HINNs and HRRs 1. The Hospital Case Manager (HCM) 13 or designee 14 must conduct a clinical review of Medicare inpatients and potential inpatients using INTERQUAL or other Tenet approved clinical screening criteria including discharge screens. 2. If a Medicare beneficiary does not meet admission or continued stay INTERQUAL or other Tenet approved clinical screening criteria, the HCM must contact the attending physician to determine whether there is additional clinical information that is not documented in the medical record and to request that the attending physician document any additional pertinent information. 12 For expedited review, the beneficiary must request QIO review in writing or by telephone no later than the day of discharge. The QIO is available to accept the beneficiary discharge appeals 24 hours a day, seven days a week. After discharge, a beneficiary may request QIO review within 30 calendar days of the date of discharge, or at any time for good cause. 13 Case Manager or other individual identified by the Tenet Hospital as being primarily responsible for issuing HINNs, Detailed Notices, and Hospital Review Requests. 14 This function might be performed by the House Supervisor, Charge Nurses, Patient Access, Case Management staff, Nursing Supervisor and/or DCQI as assigned and designated by the Tenet Hospital.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 8 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 3. If the attending physician provides additional documentation, the HCM must re-evaluate the case. 4. If the beneficiary still fails to meet admission or continued stay INTERQUAL or other Tenet approved clinical screening criteria, the HCM must refer the case to the Physician Advisor (PA) of the Utilization Management (UM) Committee for review. See Attachment A for process flows. 5. If the PA of the UM Committee concludes that a beneficiary does not meet medical necessity for admission or continued stay, the HCM must issue a HINN to notify the beneficiary that the stay does not meet inpatient criteria; that the services will not be covered by Medicare; and that the beneficiary will be financially responsible for services rendered from the date and time noted in the HINN. 6. Common situations requiring Medicare beneficiary notices are described below, along with applicable procedures. 15 a. Preadmission Determinations When a beneficiary s attending physician has ordered an inpatient admission, but preadmission review indicates that the beneficiary does not meet criteria for inpatient admission, the individuals designated by the Tenet Hospital must issue a preadmission HINN. 16 b. Determinations after Admission, but on the Date of Admission When it is determined after admission, but still on the date of admission, that a beneficiary who has been admitted as an inpatient never met medical necessity criteria for hospital services, and the attending physician does not discharge the beneficiary, the individuals designated by the Tenet Hospital must issue an Admission HINN notice on the date of admission. 17 15 There may also be circumstances when items or services are requested for an inpatient that are excluded from Medicare coverage by a Local Coverage Determination (LCD), National Coverage Determination or other national Medicare policy for a beneficiary who requires continued hospital care. Although Medicare will not reimburse Tenet Hospital for such items or services, hospital are permitted to bill beneficiaries for such items and services if the patient is notified through a HINN 11 AND all of the following criteria are satisfied: (1) continued inpatient stay is reasonable and necessary, (2) the item or service requested is not bundled into or integral to payment or treatment for the diagnoses supporting the covered inpatient stay and (3) the item or service requested is noncovered based on a national coverage policy or LCD. See 42 C.F.R. 412.42(d). When these situations are identified, Regional Counsel must be contacted to confirm the applicability of HINN 11 and further instructions. 16 A Preadmission HINN notice may be issued without physician concurrence; however, Tenet Hospitals may choose to have the case reviewed by the PA and a second physician member of the UM Committee. 17 Admission HINNs issued before 3PM on the date of admission establish beneficiary financial liability for services furnished after receipt of the notice. Admission HINNs issued after 3PM on the date of admission establish beneficiary financial liability for services furnished on the days following the admission date.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) c. Determinations after the Date of Admission 18 Page: 9 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 (1) Beneficiary Never Met Inpatient Criteria (a) (b) When a beneficiary is found after the date of admission never to have met INTERQUAL or other Tenet approved clinical screening criteria for admission, but the attending physician does not discharge the beneficiary, 19 an Admission HINN is no longer appropriate, and the case must be referred to the UM Committee for review by the PA and a second physician member of the UM Committee. If the PA and a second physician member of the UM Committee agree that the beneficiary did not meet criteria for admission, but the beneficiary s attending physician does not concur, the Tenet Hospital must contact the QIO and issue a Notice of HRR to inform the beneficiary that the Tenet Hospital has requested QIO review of the discharge decision because the attending physician does not concur. See procedures for Tenet Hospital requests for QIO review in Section IV.B.7., below. (2) Beneficiary Originally Met, but No Longer Meets Inpatient Criteria and Attending Physician Concurs When a continued stay review indicates that the beneficiary no longer meets inpatient criteria, that discharge screens are met, and that the attending physician agrees with the determination (i.e., writes a discharge order) a Follow-up Notice indicating the planned discharge date must be given to the beneficiary or beneficiary s representative. See Section IV.A.2 of this policy, above. The beneficiary must be allowed four hours prior to discharge to evaluate and exercise their rights to appeal. (a) If the beneficiary or beneficiary s representative refuses discharge and requests expedited QIO review follow Section IV.A.2., above. 18 The type of notice to be issued and effect of notice on beneficiary financial liability regarding determinations after the date of admission depends on the nature and basis for the hospital determination. 19 When the attending physician concurs, a Follow-up Notice will be given to the beneficiary indicating the planned discharge date. See Section IV.A.2, above, regarding this process and procedures.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 10 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 (b) (c) If the beneficiary does not seek expedited QIO review, but still refuses to be discharged, the Tenet Hospital s designated individuals must prepare and issue a Continued Stay HINN (HINN12) to the beneficiary; 20 The Tenet Hospital s designated individuals must have the beneficiary date and sign the HINN and must contact the appropriate individuals to work with the patient to make financial arrangements for satisfaction of the beneficiary s account for services subject to the HINN. 21 (i) (ii) (iii) If the beneficiary is incapable of reading or understanding the HINN, the HCM must speak with the beneficiary s representative in person to obtain a signature, or if necessary, attempt to discuss the notice by telephone with the beneficiary s representative and simultaneously mail the notice to the beneficiary s representative by certified mail with return receipt requested. The HCM may also use email, consistent with Tenet s information privacy and security policies and standards, to request a telephone call from the representative, but leaving a voice mail message is not sufficient for this purpose even if consistent with Tenet s information privacy and security policies and standards. When direct telephone contact with the beneficiary s representative cannot be made, the HCM must mail the notice by certified mail, with return receipt requested. 22 If the beneficiary is unable to read or understand the notice and the beneficiary 20 This HINN will establish the beneficiary s financial responsibility for the services subject to the beneficiary s right to appeal to the QIO after discharge. 21 If the patient refuses to make financial arrangements the case shall be immediately referred to the Chief Financial Officer and Compliance Officer for resolution. 22 In this situation, the date that the letter is signed for at the address of the representative is considered the date of receipt.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 11 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 has no representative, the HCM attempting to deliver the notice must clearly document his or her search for a beneficiary representative on a copy of the HINN to be placed in the beneficiary s medical record. (iv) (v) (vi) (vii) If the beneficiary or representative refuses to sign the HINN, the HCM must document who refused to sign and the date of the refusal. The HCM must initial and date the annotation. A copy of the signed or otherwise annotated Continued Stay HINN-12 must be retained in the beneficiary s medical record. The original document must be given to the beneficiary or representative. Within 24 hours of a signed or otherwise annotated Continued Stay HINN-12, the Tenet Hospital s designated individual must notify the Hospital s Director of Revenue Analysis (DRA). The DRA must immediately place the patient account on manual bill hold. The HCM and DRA must notify the billing department that a HINN-12 has been issued by completing Section 1: HINN-12 Issued For Non-Covered Continued Stay of the form Medicare Non-Covered Continued Stay (see Attachment E). Following the instructions on the form, the manual bill hold is released once all steps have been completed. (3) Beneficiary Originally Met, but No Longer Meets Inpatient Criteria and Attending Physician Does Not Concur (a) When a continued stay review indicates the beneficiary no longer meets inpatient criteria and that discharge screens are met, but the attending physician does not agree with the determination and
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 12 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 does not discharge the beneficiary, the case must be referred to the UM Committee for review. (b) If the PA and a second physician member of the UM Committee agree that the beneficiary no longer meets criteria for inpatient care, but the beneficiary s physician still does not concur, the Tenet Hospital must contact the QIO and issue a Notice of HRR to notify the beneficiary that the Tenet Hospital has requested QIO review of the discharge decision because the attending physician does not concur. See procedures for Tenet Hospital requests for QIO review in Section IV.B.7., below. 7. Hospital Requests for QIO Review HRR a. When the beneficiary s attending physician disagrees with the determination of the UM Committee that a beneficiary no longer needs inpatient care, the individuals designated by the Tenet Hospital must request QIO review of the case. b. In these circumstances, the HCM must contact the Director of Case Management for guidance and the Director of Case Management must initiate the QIO review process. See Attachment A for process flows. c. Concurrently, the HCM must notify the beneficiary that the Tenet Hospital has requested a review using a model language for the notice of HRR. The Tenet Hospital s designated individuals must simultaneously distribute copies of the HRR to: the beneficiary; Case Management files; the beneficiary s medical record; the beneficiary s attending physician, and the QIO. d. The transmission to the QIO must be labeled Attention: Immediate Review and must include a copy of the relevant medical records, a copy of the IMFM, any Follow-up Notice(s) and a copy of the HRR. The HCM must also assemble and supply any pertinent information that the QIO needs to conduct its review by telephone or in writing, by close of business on the first full day immediately following the date the Tenet Hospital submitted the HRR request for review. 23 23 After receiving the HRR, the QIO is required to notify the hospital that it has received the request for review and must notify the hospital if it has not received pertinent records. The QIO is to solicit comment regarding the case from the hospital, attending physician, and beneficiary. The medical record and comments are to be referred to a
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 13 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 8. Detailed Notice of Discharge (Detailed Notice): Beneficiary QIO Appeals 24 a. When the Tenet Hospital receives notice that that a beneficiary has requested an expedited determination by the QIO, the Tenet Hospital s designated individuals must prepare a Detailed Notice (CMS 10066) to advise the beneficiary in full sentences using plain language regarding the planned discharge date, why the services are no longer reasonable and necessary (or are otherwise noncovered), applicable Medicare coverage policies and specific information about the beneficiary s current medical condition rendering the identified coverage policies applicable and supporting the decision to discharge on the indicated date. b. The Tenet Hospital s designated individuals must deliver the Detailed Notice to the beneficiary and to the QIO as soon as possible, but not later than noon of the day after the Tenet Hospital received notice of the appeal from the QIO. c. The Case Management staff must also compile any documentation and information required by the QIO for this determination, including the IMFM and the Detailed Notice, and forward that documentation to the QIO and/or respond to telephone inquiries from the QIO no later than noon of the day following the date the Tenet Hospital received notice of the appeal from the QIO. 25 The QIO physician reviewer who may also discuss the case with the attending physician. The QIO will determine whether the services (1) are reasonable and medically necessary, (2) meet professionally recognized standards of care, and (3) could be safely delivered in another setting and will notify the beneficiary, the hospital, and the attending physician of its decision by telephone (and subsequently in writing) within two (2) days of the hospital s request and receipt of any pertinent information submitted by the hospital. The written notice of the expedited initial determination will contain the following: The basis for the determination; a detailed rationale for the determination; a statement explaining the Medicare payment consequences of the expedited determination and the date of liability if any; and a statement informing the beneficiary of his or her appeal rights and the timeframe for requesting an appeal. The expedited QIO determination is binding on the beneficiary, attending physician and the Hospital, unless the beneficiary remains in the Hospital and requests a reconsideration by an independent review entity (IRE). When a beneficiary who is no longer an inpatient in the hospital is dissatisfied with a QIO determination, the determination is subject to the general claims appeal process outlined in Medicare Claims Processing Manual Chapter 29. 24 See 42 C.F.R. 405.1206 (expedited determination procedures for inpatient care) and 42 C.F.R. 422.622 (immediate QIO review of Medicare Advantage discharge determinations). 25 Failure to meet these deadlines may result in delay of the expedited determination and additional financial exposure to the hospital. The QIO must normally render its determination within one calendar day after it receives the requested information. When a timely appeal has been filed, the beneficiary does not become financially responsible (other than for applicable coinsurance and deductible amounts) for services furnished prior to noon on the day after the beneficiary received notice of the QIO determination orally or in writing.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) Page: 14 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 HCM must respond to all inquiries from the QIO regarding the appeal and discharge decision. 26 d. If the beneficiary requests copies of the documentation and/or information provided to the QIO (or any portion of it), 27 the Tenet Hospital s designated individuals must provide the requested copies and information to the beneficiary by close of business on the day after the request is received by the Tenet Hospital. e. Within 24 hours of the beneficiary s request for a QIO review, the HCM must notify the DRA of the pending QIO determination. The DRA will immediately place the patient account on manual bill hold. f. When the QIO determination is received, the HCM and DRA will determine if there is continued stay patient liability: (1) If the QIO determination upholds the discharge and the review was requested timely, patient liability begins no sooner than noon on the day after the patient received notice of the QIO determination (see Section IV.B.8.c., above). (2) If the QIO determination upholds the discharge but the review was not requested timely, patient liability begins on a date as determined by the QIO (see Section IV.B.7.d., above). When there is patient liability, the HCM and DRA notify the billing department by completing Section 2: QIO Review for Continued Stay of the form Medicare Non-Covered Continued Stay (see Attachment B). Following the instructions on the form, the manual bill hold will be released once all steps have been completed. If the QIO does not uphold the discharge, there is no patient liability for continued stay. In this instance, no notification to the billing department is required and the DRA may release the bill hold. All inquiries, requests for records and any determinations for any 26 The QIO is required to provide an opportunity for the hospital to explain why the discharge is appropriate. 27 The Detailed Notice also asks whether the beneficiary would like a copy of the documents that have or are being sent to the QIO in connection with the appeal.
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) C. Compliance Monitoring Page: 15 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 HINN for Medicare Inpatients related to QIO appeals must be documented/maintained in the Case Management Documentation System/Log. A pattern of failure to issue beneficiary notices in accordance with this policy must be reported as a compliance issue pursuant to Regulatory Compliance policy COMP-RCC 4.21 Internal Reporting of Potential Compliance Issues. D. Responsible Person The Director of Case Management shall be responsible for assuring that all personnel adhere to the requirements of this policy, that these procedures are implemented and followed at the Tenet Hospital, and that instances of noncompliance with this policy are reported to the Compliance Officer. E. Enforcement V. REFERENCES: All employees whose job responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law. - Quality, Compliance, and Ethics Program Charter - Regulatory Compliance policy COMP-RCC 4.18 Clinical Determination of Appropriate Patient Status - Regulatory Compliance policy COMP-RCC 4.21 Internal Reporting of Potential Compliance Issues - 42 C.F.R. 412.42(c), (d) and (g) - 42 C.F.R. 482.30-42 C.F.R. 405.1205-405.1208 - Medicare Claims Processing Manual 100-04, Chapter 29 - Medicare Claims Processing Manual 100-04, Chapter 30
Regulatory Compliance Policy No. COMP-RCC 4.25 Title: HOSPITAL COVERAGE NOTICES FOR MEDICARE INPATIENTS (INCLUDING IMPORTANT MESSAGE FROM MEDICARE) - CMS Beneficiary Notices Initiative (BNI) website Page: 16 of 16 Effective Date: 03-19-15 Retires Policy Dated: 01-30-14 Previous Versions Dated: 09-27-11; 06-06-11; 10-13-10; 06-28-04 VI. ATTACHMENTS: Attachment A: Process Flows Attachment B: HINN 1 PreAdmission/Admission Form Attachment C: HINN 10 Hospital Requested Review Form Attachment D: HINN 11 Non-Covered Services for Continued Stay Attachment E: HINN 12 Medicare Non-Covered Continued Stay Form Attachment F: Important Message from Medicare Attachment G: Detailed Notice of Discharge
Important Message from Medicare Flow Process Patient Access issues IMFM package to Medicare Beneficiary to obtain signatures, provides signed copies for beneficiary and medical record. Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 7 Within 2 days prior to discharge, HCM or designee reviews with patient/representative, provides follow-up copy of IMFM and their right to appeal. Signed copy to patient and medical record Beneficiary refuses to sign the follow up IMFM AND disagrees with discharge AND refuses to exercise expedited appeal rights to the QIO, a HINN 12 is to be issued to the patient. HCM/designee notifies DRA of HINN12 issuance. DRA places patient account on hold. DRA and HCM complete the Medicare Non-Covered Continued Stay form, Section 1 before releasing account. Medicare Beneficiary/representative disagrees with discharge and chooses an Expedited Appeal and notifies the QIO in writing or by telephone no later than the day of discharge HCM/designee notifies Nursing and Physician of decision to appeal, and instructs DRA to place patient account on hold. QIO notifies Hospital of appeal Beneficiary agrees with Discharge Upon notification from the QIO, the HCM or designee must issue a Detailed Notice of Discharge (CMS-10066) to the beneficiary/representative and the QIO by noon of the day after notification. The following information must be sent to QIO: Detailed Notice of Discharge, copy of medical record, and any other information requested by the QIO QIO Decision QIO agrees with discharge. The QIO will notify Hospital, Physician, and Beneficiary when coverage will end. QIO disagrees with discharge. The QIO will notify Hospital, Physician, and Beneficiary of outcome/determination. HCM/designee and DRA complete the Medicare Non-Covered Continued Stay form, Section 2 before releasing account. HCM/designee notify DRA. DRA releases account. 03-19-15
Pre-Admission HINN Flow Process Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 2 of 7 P.A. determines medical necessity Not Met for admission based on secondary review of pre-admission patient data following referral from HCM HCM/designee issues preadmission HINN to beneficiary/representative and informs them of appeal rights HCM/designee provides copy to patient, QIO, physician, business office and medical record Patient decides to be admitted and appeal decision; admit according to physician s orders HCM/HIM provides requested medical record documentation to QIO as needed to facilitate appeal 03-19-15
Admission HINN Flow Process P.A. determines medical necessity Not Met for admission based on secondary review of admission patient data following referral from HCM * Must be completed on day of admission* Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 3 of 7 HCM/designee issues admission HINN to beneficiary/representative and informs them of appeal rights *Must be completed on day of admission* HCM/designee provides copy to patient, QIO, physician, business office and medical record Patient decides to stay, admit according to physician s orders HCM/HIM provides requested medical record documentation to QIO as needed to facilitate appeal 03-19-15
Secondary Review Flow Process Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 4 of 7 HCM finds that additional information provided by the attending physician does not support status and/or level of care Case Manager refers to PA for secondary review PA reviews record, discusses with attending and other MD as needed PA overturns results of screening tool and confirms medical necessity is met PA upholds results of screening tool and determines medical necessity is not met PA documentation supports his or her clinical decision 03-19-15
HRR (Hospital Requested Review) Flow Process -HINN 10 Beneficiary never met inpatient criteria, physician does not discharge (HINN no longer appropriate based on timeframe) Beneficiary originally met, but no longer meets inpatient criteria and upheld by secondary review, and the discharge screens are met, but attending does not concur Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 5 of 7 Case Manager refers case to the PA for secondary review and a second physician member of the UMC reviews the case PA and the second physician member of the UMC agree that the beneficiary does not meet inpatient criteria and the attending physician does not concur and does not discharge HCM shall initiate the QIO review, concurrently must notify the beneficiary using the model language of the Hospital Requested Review (HRR) Simultaneously hospital designee distributes copies of the HRR to: the beneficiary; Case Management; the beneficiary s medical record; the beneficiary s attending physician; and the QIO Label transmission to QIO Attention: Immediate Review and shall include a copy of relevant medical record, copy of IMFM(s) and a copy of HRR and be available for follow-up by telephone or in writing with the QIO to supply any requested pertinent information 03-19-15
Non-covered Service During Covered Stay HINN 11 Flow Process Physician orders item or service (test, therapy, equipment) which may not be covered under Local Coverage Determination (LCD) or National Coverage Determination (NCD) policy Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 6 of 7 HCM uses the screening tool and confirms that continued stay is medically necessary HCM confirms with Director of Revenue Analysis or designee that item or service is non-covered HCM notifies physician and physician requests item or service as ordered HCM provides HINN 11 to patient/beneficiary Beneficiary/designee accepts financial responsibility, item or service is provided as ordered Beneficiary/designee does not accept financial responsibility, issue is escalated to the A Team 03-19-15
Detailed Notice of Discharge (Detailed Notice)-CMS 10060 Flow Process Attachment A COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 7 of 7 Discharge Order written or P.A. determines medical necessity Not Met for continued stay based on secondary review of patient data following referral from HCM, follow-up IMFM issued, beneficiary requests expedited review by the QIO and the QIO notifies the hospital of the patient s decision to appeal HCM/designee shall prepare a Detailed Notice to advise the beneficiary in full sentences using plain language regarding the planned discharge date, why the services are no longer reasonable and necessary (or otherwise noncovered) and applicable Medicare coverage policies HCM/designee provides copy to beneficiary, QIO, attending physician, business office and medical record. HCM/designee notifies DRA to place manual hold on patient account. HCM/HIM provides requested medical record documentation including IMFM and any follow-up notices, Detailed Notice, to the QIO as needed to facilitate appeal no later than Noon of the day following the date Hospital received notice of the appeal from the QIO, if requested by beneficiary a copy of information sent to the QIO is provided Beneficiary discharge on hold pending decision of the QIO 03-19-15
Attachment B COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 2 240.6 Exhibit 4 Model Language for Preadmission/Admission Hospital Issued Notice of Noncoverage. Hospital Identifier Preadmission or Admission Hospital-Issued Notice of Noncoverage (HINN) Model Language Name of Patient: Patient ID Number: Name of Physician: Date Issued: We believe that Medicare is not likely to pay for your admission for (specify service or condition) it is not considered to be medically necessary it could be furnished safely in another setting other because: 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: CONTINUED ON PAGE 2 1 1 For preadmission notices, insert: "customary charges for all services furnished during the stay, except for those services for which you are eligible under Part B." For admission notices issued not later than 3:00 P.M. on the date of admission, insert: "customary charges for all services furnished after receipt of this hospital notice, except for those services for which you are eligible under Part B." (If these requirements are not met, insert the liability phrase below.) For admission notices issued after 3:00 P.M. on the day of admission, insert: "customary charges for all services furnished on the day following the day of receipt of this notice, except for those services for which you are eligible to receive payment under Part B." 01-30-14
If you want an immediate review of your case: Preadmission: Admission: Attachment B COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 2 of 2 (insert one of the following as appropriate) 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. Call the QIO immediately at the number listed below or you may call the QIO at any point during your stay. You may also call the QIO for quality of care issues. QIO Contact Information: (insert telephone number of QIO) If you do not want an immediate review: (insert name of QIO in bold) 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 below. 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). (see footnote 1 on page 1). For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-87 -486-2048. Please sign your name, the date and time. Your signature does not mean that you agree with this notice, just that you received the notice and understand it. Signature of Patient or Representative Date Time 01-30-14
Attachment C COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 1 220.5 Exhibit 3 Model Language for Notice of Hospital Requested Review. (Rev.) Hospital Identifier Model Notice of Hospital Requested Review (HRR) Name of Patient: Name of Physician: Patient ID Number: Date Issued: We believe that Medicare will not continue to cover your hospital care because these services are no longer considered medically necessary in your case. Because your doctor disagreed with our finding, the hospital is asking the quality improvement organization (QIO) to review your case. The QIO is an outside reviewer hired by Medicare to look at your case to decide if you are ready to leave the hospital. The name of the QIO is (insert the name of the QIO). The QIO will contact you to solicit your views about your case and the care you need. You do not need to take any action until you hear from the QIO. For more information about this notice, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. Please sign your name, the date and time. Your signature does not mean that you agree with this notice, just that you received the notice and understand it. Signature of Patient or Representative Date Time 01-30-14
Attachment D COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 2 Letter 11 - Model HINN - Noncovered Service(s) during Covered Stay Name of Patient or Representative Date of Notice Street Address Admission Date City, State, Zip Code Attending Physician Health Insurance Claim (HIC) Number YOUR IMMEDIATE ATTENTION IS REQUIRED The purpose of this notice is to inform you that: (Blank 1 Service name) is/are not covered under Medicare because: (Blank 2 Reason for Noncoverage) Our opinion was based upon the following Medicare policy we and our Medicare intermediary follow: (Blank 3 Justification of Assessment of Noncoverage).. If you decide to receive the service(s) listed above, based on our customary charges for this/these service(s), you will have payment responsibility for: (Blank 4 Patient Financial Responsibility). Your attending physician has been advised of our opinion. You should talk with your physician about your health care needs, including the service(s) listed above. RECEIPT OF THIS NOTICE This notice is not an official Medicare decision. Your signature below only shows you have received the notice and understand what you may have to pay for. On the next page is information to use if you get the service(s) and you want to ask Medicare if it agrees with our opinion. Note we will also give a copy of this notice to your physician listed above. Signature of Beneficiary or Representative Date 03-19-15
Attachment D COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 2 of 2 YOUR RIGHT TO A MEDICARE REVIEW (APPEAL): You can ask us to file a Medicare claim for the service(s) listed on this notice. You will receive a Medicare Summary Notice (MSN) telling you Medicare s payment decision on this/these service(s), and how to ask for an appeal of that decision if Medicare does not pay. If Medicare has covered your hospital stay, it reviews any individual service it does not cover during that stay, only after you file a claim. If you appeal and Medicare decides to pay despite our opinion, any charges we collected will be refunded to you. You can ask your physician among others to represent you in filing an appeal. Your Medicare intermediary does the formal review and makes the payment decision on the service(s) listed on this notice when processing the related claim. If you have questions on that claim or the MSN for the service(s) listed on this notice, you can contact your intermediary. Your intermediary contact information: (Blank 5 Intermediary name, address, and telephone number) Quality Improvement Organizations (QIOs) in each State do certain types of reviews for Medicare, including judging the need for certain medical services and quality of care. You can ask your QIO in your State to review the service(s) listed on this notice after you have received them. Your QIO contact information: (Blank 6 QIO Name, address, and telephone number) Sincerely, (Blank 7- Hospital Signature).. 03-19-15
xx-xx-xx Hospital Patient Name Medicare Non-Covered Continued Stay Form Attachment E COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 o f 1 Account Number Admit Date Section 1: HINN-12 Issued For Non-Covered Continued Stay Complete this section when a discharge order has been received, the patient has elected to remain in the hospital, and has signed a HINN-12. Hospital Case Manager (HCM): 1. Please provide the following information: Date of discharge order Date patient signed HINN-12 Date patient liability begins (usually the same as date of signed HINN-12. If different, please explain). DRA uses for from in 2b below. Date patient actually left hospital. DRA uses for through in 2b below. Hospital Case Managers Initials and Date 2. Forward this form and a copy of the completed and signed HINN-12 to your hospital DRA. Director of Revenue Assurance (DRA): 1. Account should have previously been placed on manual bill hold based on notification from HCM of signed HINN-12 (per policy COMP-RCC 4.25) 2. Enter the following info onto the hospital s billing system account: a. Occurrence Code 31 (Date Beneficiary Notified of Intent to Bill) b. Occurrence Span Code 74 (span is from date patient liability began to date patient actually left hospital) 3. Scan copy of HINN-12 and this completed form into the non-clinical section of the medical record. 4. Release the account from manual bill hold. DRAs Initials and Date Section 2: QIO Review for Continued Stay Complete this section when a discharge order has been received, the patient requested QIO review, QIO agreed with discharge order, and there is patient liability for the continued stay (per policy COMP-RCC 4.25). Hospital Case Manager (HCM): 1. Please provide the following information: Date of discharge order Date patient requested QIO Review Date QIO decision to uphold discharge received Date patient liability begins (if other than day after QIO decision to uphold, please explain)* DRA uses for from in 2b below. Date patient actually left hospital. DRA uses for through in 2b below. Hospital Case Managers Initials and Date 2. Forward this form and a copy of the QIO determination documentation to the hospital DRA. Director of Revenue Assurance (DRA): 1. Account should have previously been placed on manual bill hold based on notification from HCM of a pending QIO determination (per policy COMP-RCC 4.25) 2. Enter the following info onto the hospital s billing system account: a. Occurrence Code 31 (Date Beneficiary Notified of Intent to Bill) b. Occurrence Span Code 74 (span is from date patient liability began to date patient actually left hospital) 3. Scan copy of this completed form and the QIO determination documentation into the non-clinical section of the medical record. 4. Release the account from manual hold. DRAs Initials and Date *When patient fails to request a timely QIO review (i.e., prior to midnight on the day of the discharge order), and remains in the hospital, he or she may still request a QIO review. However, the QIO may determine that the beneficiary is responsible for charges incurred on or even prior to the date of the QIO decision, depending upon how delinquent the patient was in requesting the review. * When patient has requested a timely QIO review, liability can never start sooner than date of discharge order +2 days. 03-19-15
Patient Name: Patient ID Number: Physician: Attachment F COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 3 Important Message From Medicare An Important Message From Medicare About Your Rights As A Hospital Inpatient, You Have The Right To: Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them. Be involved in any decisions about your hospital stay, and know who will pay for it. Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here: Name of QIO Telephone Number of QIO Your Medicare Discharge Rights Planning For Your Discharge: During your hospital stay, the hospital staff will be working with you to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date. If you think you are being discharged too soon: You can talk to the hospital staff, your doctor and your managed care plan (if you belong to one) about your concerns. You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by Medicare to look at your case to decide whether you are ready to leave the hospital. If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital. If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles). If you do not appeal, but decide to stay in the hospital past your planned discharge date, you may have to pay for any services you receive after that date. Step by step instructions for calling the QIO and filing an appeal are on page 2. To speak with someone at the hospital about this notice, call. Please sign and date here to show you received this notice and understand your rights. Signature of Patient or Representative Date/Time Form CMS-R-193 (approved 07/10) 03-19-15
Steps To Appeal Your Discharge Attachment F COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 2 of 3 Step 1: You must contact the QIO no later than your planned discharge date and before you leave the hospital. If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles). Here is the contact information for the QIO: Name of QIO (in bold) Telephone Number of QIO You can file a request for an appeal any day of the week. Once you speak to someone or leave a message, your appeal has begun. Ask the hospital if you need help contacting the QIO. The name of this hospital is : Hospital Name Provider ID Number Step 2: You will receive a detailed notice from the hospital or your Medicare Advantage or other Medicare managed care plan (if you belong to one) that explains the reasons they think you are ready to be discharged. Step 3: The QIO will ask for your opinion. You or your representative need to be available to speak with the QIO, if requested. You or your representative may give the QIO a written statement, but you are not required to do so. Step 4: The QIO will review your medical records and other important information about your case. Step 5: The QIO will notify you of its decision within 1 day after it receives all necessary information. If the QIO finds that you are not ready to be discharged, Medicare will continue to cover your hospital services. If the QIO finds you are ready to be discharged, Medicare will continue to cover your services until noon of the day after the QIO notifies you of its decision. If You Miss The Deadline To Appeal, You Have Other Appeal Rights: You can still ask the QIO or your plan (if you belong to one) for a review of your case: If you have Original Medicare: Call the QIO listed above. If you belong to a Medicare Advantage Plan or other Medicare managed care plan: Call your plan. If you stay in the hospital, the hospital may charge you for any services you receive after your planned discharge date. For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048. Additional Information: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0692. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Form CMS-R-193 (approved 07/10) 03-19-15
Attachment F COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 3 of 3 Completing The Notice Notice Instructions: The Important Message From Medicare Page 1 of the Important Message from Medicare A. Header Hospitals must display Department of Health & Human Services, Centers for Medicare & Medicaid Services and the OMB number. The following blanks must be completed by the hospital. Information inserted by hospitals in the blank spaces on the IM may be typed or legibly hand-written in 12-point font or the equivalent. Hospitals may also use a patient label that includes the following information: Patient Name: Fill in the patient s full name. Patient ID number: Fill in an ID number that identifies this patient. This number should not be, nor should it contain, the social security number. Physician: Fill in the name of the patient s physician. B. Body of the Notice Bullet number 3 Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here. Hospitals may preprint or otherwise insert the name and telephone number (including TTY) of the QIO. To speak with someone at the hospital about this notice call: Fill in a telephone number at the hospital for the patient or representative to call with questions about the notice. Preferably, a contact name should also be included. Patient or Representative Signature: Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents. Date/Time: Have the patient or representative place the date and time that he or she signed the notice. Page 2 of the Important Message from Medicare First sub-bullet Insert name and telephone number of QIO in bold: Insert name and telephone number (including TTY), in bold, of the Quality Improvement Organization that performs reviews for the hospital. Second sub-bullet The name of this hospital is: Insert/preprint the name of the hospital, including the Medicare provider ID number (not the telephone number). Additional Information: Hospitals may use this section for additional documentation, including, for example, obtaining beneficiary initials, date, and time to document delivery of the follow-up copy of the IM, or documentation of refusals. Form CMS-R-193 (approved 07/10) 03-19-15
Attachment G COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 1 of 2 Patient Name: OMB Approval No. 0938-1019 Patient ID Number: Date Issued: Physician: {Insert Hospital or Plan Logo here} Detailed Notice Of Discharge You have asked for a review by the Quality Improvement Organization (QIO), an independent reviewer hired by Medicare to review your case. This notice gives you a detailed explanation about why your hospital and your managed care plan (if you belong to one), in agreement with your doctor, believe that your inpatient hospital services should end on. This is based on Medicare coverage policies listed below and your medical condition. This is not an official Medicare decision. The decision on your appeal will come from your Quality Improvement Organization (QIO). Medicare Coverage Policies: Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished in another setting. (Refer to 42 Code of Federal Regulations, 411.15 (g) and (k)). Medicare Managed Care policies, if applicable: {insert specific managed care policies} Other {insert other applicable policies} Specific information about your current medical condition: If you would like a copy of the documents sent to the QIO, or copies of the specific policies or criteria used to make this decision, please call {insert hospital and/or plan telephone number}. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1019. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS 10066 (approved 07/10) 03-19-15
Attachment G COMP-RCC 4.25 Hospital Coverage Notices for Medicare Inpatients Page 2 of 2 Instructions for Completing the Detailed Notice of Discharge CMS 10066 This is a standardized notice. Hospitals may not deviate from the content of the form except where indicated. Please note that the OMB control number must be displayed on the notice. Insertions must be typed or legibly hand-written in 12-point font or the equivalent. Hospitals or plans may modify the following sections to incorporate use of a sticker or label that includes this information: Patient Name: Fill in the patient s full name. Patient ID number: Fill in the patient s ID number. This should not be, nor should it contain, the patient s social security or HICN number. Physician: Fill in the name of the patient s physician. Date Issued: Fill in the date the notice is delivered to the patient by the hospital/plan. Insert logo here: Hospitals/plans may elect to place their logo in this space. However, the name, address, and telephone number of the hospital/plan must be immediately under the logo, if not incorporated into the logo. If no logo is used, the name and address and telephone number (including TTY) of the hospital/plan must appear above the title of the form. BLANK 1: This notice gives you a detailed explanation of why your hospital and your managed care plan (if you belong to one), in agreement with your doctor, believe that your inpatient hospital services should end on. In the space provided, fill in planned date of discharge. First Bullet: Medicare Coverage Policies: Place a check next to the applicable Medicare and/or managed care policies. If necessary, hospitals may also use the selection Other to list other applicable policies, guidelines or instructions. Hospitals or plans may also preprint frequently used coverage policies or add more space below this line, if necessary. Policies should be written in full sentences and in plain language. In addition, the hospital or plan may attach additional pages or specific policies or discharge criteria to the notice. Any attachments must be included with the copy sent to the QIO as well. Second Bullet: Specific information about your current medical condition Fill in detailed and specific information about the patient s current medical condition and the reasons why services are no longer reasonable or necessary for this patient or are no longer covered according to Medicare or Medicare managed care coverage guidelines. Use full sentences and plain language. Third Bullet: If you would like a copy of the documents sent to the QIO, or copies of the specific policies or criteria used to make this decision, please call. The hospital/plan should also supply a telephone number for patients to call to get a copy of the relevant documents sent to the QIO. If the hospital/plan has not attached the Medicare policies and/or the Medicare managed care plan policies used to decide the discharge date, the hospital should supply a telephone number for patients to call to obtain copies of this information. Hospitals or plans may add space below this section to insert a signature line and date, if they so choose. CMS 10066 (approved 07/10) 03-19-15