Hospital Issued Notices of Noncoverage

1
NORTHEAST HEALTH CARE QUALITY FOUNDATION

• Hospital Issued Notices of Non-coverage
• Presented by
• Roxanne Carpenito, RN, CPUM
• November 2005

The enclosed material was prepared and assembled
by Northeast Health Care Quality Foundation
(NHCQF), the Medicare Quality Improvement
Organization (QIO) for Maine, New Hampshire and
Vermont, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
The contents presented do not necessarily
reflect CMS policy. 1105-320
2
Overview

• Provider Settings
• Review Notices and Liability
• Concurrence
• Issue Notice Process

3
Provider Settings

• Acute Care Hospital Settings
• DRG Reimbursed
• General Acute Care Inpatient Hospital
• Non-DRG Reimbursed
• CAH
• Specialty Hospital/Unit
• Non Acute Care Hospital Settings
• Swing Beds

4
Admission Type Notices

• Applies to all acute hospital settings
• DRG hospitals with and without swing beds
• CAH hospitals with and without swing beds
• Non-DRG specialty hospitals and units

5
Preadmission Notice

• HIN 3
• Patient admitted to acute level bed at less than
  acute level of care
• Patient liability begins after patient is
  admitted
• Remember, the patient needs to be admitted, if
  remains in observation, the patient is not
  incurring liability

6
Admission Notice

• HIN 6
• Patient admitted to acute level bed at less than
  acute level of care
• Patient liability begins on admission
• This notice is given after patient admitted but
  no later than 3PM on day of admission only

7
Late Admission Notice

• HIN 8
• Patient admitted to acute level bed at less than
  acute level of care
• Patient liability begins on day after notice
  issued
• This notice is given after admission
• after 3PM on day of admission, or
• any time on subsequent days of stay

8
Admission Late Admission NoticeNo Verbal
Notice - Certified Mail

• HIN 11
• Patient admitted to acute level bed at less than
  acute level of care
• Patient liability begins day after certified
  letter signed for or refused. Need certified
  receipt.

9
Admission To Swing Bed

• Direct Admission is when patient comes from
  outside of hospital or from outpatient setting
  and includes
• ED, Observation, ASU
• Transfer from another hospital or nursing
  facility
• home

10
Eliminated Notices

• Admission type notices to non-acute settings SNF
  and ICF swing beds
• HIN 4 - Preadmission to SNF Swing Bed
• HIN 5 - Preadmission to ICF Swing Bed
• HIN 7 - Admission to ICF Swing Bed
• HIN 9 Late Admission to ICF Swing Bed
• HIN 10 - Admission or Late admission to SNF
  Swing Bed
• HIN 12 Late Admission to SNF Swing Bed
  (certified mail)
• HIN 13 Late admission to ICF Swing Bed
  (certified mail)

11
Admission to SNF Swing Bed

• Notice not required if Medicare is covering stay.
• If no 3 day qualifying stay or patient has no SNF
  benefits, need to issue a notice
• NEMB SNF CMS 20014
• http//www.cms.hhs.gov/medicare/bni/

12
Admission to ICF Swing Bed

• Notice required BUT no QIO appeal rights
• Issue a SNF ABN
• From Where SNF Manual
• www.cms.hhs.gov/manuals/12_snf/sn00.asp
• Which Notice SNF Denial Letter Exhibit 2 - UR
  Committee Determination Of Admission
• www.cms.hhs.gov/manuals/12_snf/sn335.asp_1_67

13
Continued Stay Type Notices

• Admission is considered by hospital to be an
  acute admission, you believe Medicare will pay
  for the admission
• Applies to hospital settings depending on
• DRG vs Non-DRG reimbursed
• With swing beds vs without swing beds

14
Continued Stay Notices

• HIN 14 - General Acute (DRG) Hospital without
  swing beds (with Verbal Notice)
• Patient liability begins on third day after
  notice verbally explained.
• HIN 15 General Acute (DRG) Hospital without
  swing beds (without Verbal Notice)
• Patient liability begins on third day after
  certified letter signed for or refused. Need
  certified receipt.

15
Continued Stay Notices

• HIN 16 Non-DRG Specialty Hospital/Unit CAH
  without swing beds (with Verbal Notice)
• Patient liability begins on day after notice
  verbally explained
• HIN 17 Non-DRG Specialty Hospital/Unit CAH
  without swing beds (without Verbal Notice)
• Patient liability begins on day after certified
  letter signed for or refused. Need certified
  receipt

16
SNF Refusal Continued Stay Notices

• HIN 24 All Hospitals (with Verbal Notice)
• DRG- liability begins on third day after verbally
  explained
• Non-DRG liability begins day after verbally
  explained
• HIN 25 All Hospitals (without Verbal Notice)
• DRG- liability begins on third day after
  certified letter signed for or refused. Need
  certified receipt.
• Non DRG liability begins day after signed for
  or refused. Need certified receipt.

17
All Hospitals with Swing Beds

• Means DRG Hospitals with Swing Beds Non-DRG
  Hospitals (CAH) with Swing Beds
• Transfer patient from acute level bed and now
  placing in swing bed

18
Acute to SNF Swing BedContinued Stay Notice

• HIN 18 - With Verbal Notice
• Patient covered by Medicare
• if has 3 day qualifying stay and has SNF benefit
  days
• Patient not covered by Medicare
• If not covered, patient liability begins on day
  after notice verbally explained.
• Also issue NEMB-SNF notice, discussed earlier

19
Acute to SNF Swing Bed (continued)

• HIN 19 - No Verbal Notice
• Patient covered by Medicare
• if has 3 day qualifying stay and has SNF benefit
  days
• Patient not covered by Medicare
• If not covered, patient liability begins on day
  after certified letter signed for or refused.
  Need certified receipt
• Also issue NEMB-SNF notice, discussed earlier

20
Acute to ICF Swing BedContinued Stay Notice

• HIN 20 - Acute to ICF Level (with Verbal Notice)
• Patient liability begins on day after notice
  verbally explained.
• HIN 21 - Acute to ICF Level (without Verbal
  Notice)
• Patient liability begins on day after certified
  letter signed for or refused. Need certified
  receipt.

21
Swing Bed Continued Stay Notices

• HIN 22 - Eliminated (SNF to ICF Level with
  Verbal Notice)
• HIN 23 - Eliminated (SNF to ICF Level without
  Verbal Notice)

22
New SNF to ICF Swing Bed Continued Stay Notice

• HINN 33 - Generic Notice Notice of Medicare
  Provider Non-coverage
• Liability begins on day after effective date
• HINN 34 Detailed Notice Detailed Explanation
  of Non-coverage
• Given when expedited appeal is filed

23
Obtain Concurrence

• Obtain before issuing a Continued Stay Notice
• DRG reimbursed bed, no swing bed, acute to ICF
  level (14 15)
• Non-DRG bed, no swing bed, acute to ICF level (16
  17)
• Acute to SNF swing bed (18 19)
• Acute to ICF swing bed (20 21)
• SNF bed/search refusal (24 25)

24
Concurrence

• Must be in writing
• May use MDs order as well as progress note
• Telephone order must be signed/dated by MD before
  issuing notice
• Verbal order, you write/date, MD signs
• Physician signature/Date crucial
• Use of Stamp is encouraged

25
Provide Notification

• Notification can be done
• In Person
• By Telephone
• By Certified Mail (No Verbal Notice)

26
Verbal Notification

• Decision made by the hospital, NOT Medicare
• Date patients liability will begin
• Rights to QIO review and effect on the liability
• NHCQF toll free and local telephone numbers

27
Acknowledgment

• In Person
• Recipient signs acknowledgment
• If refuses, document this on the acknowledgment
  form
• By Telephone
• Messages on voice mail or answering machines not
  acceptable
• Document telephone verbal notification
• Document date notice mailed

28
After Telephone Verbal Notice

• Mail notice with acknowledgment same day verbal
  notice provided
• Mail next day PO opens for business if verbal
  notice provided
• Sunday
• Federal Holiday
• After PO closed for day
• If requested, you may leave notice where
  representative wants, but document

29
Certified Mail with Unsuccessful Verbal
Notification

• Complete Acknowledgment
• Select Notice (states hospital unsuccessful
  attempt to contact)
• Liability begins after certified letter is signed
  for or refused

30
Certified Mail with Unsuccessful Verbal
Notification (continued)

• Continue to attempt to contact representative
• If successful contact/verbal notice, reissue a
  notice with liability documented
• Advise representative that this notice supersedes
  first one

31
Northeast Health Care Quality Foundation

• Roxanne Carpenito, RN, CPUM
• Review Services Specialist
• [phone]