QIO_Manual_Chapter_7_Attachment.pdf

ATTACHMENT TO QIO MANUAL CHAPTER 7 TOPS MEMO

Overview of Chapter 7 Review Requirements: BIPA Reviews, Grijalva Reviews, Weichardt Reviews, Hospital-Requested Reviews, Preadmission HINN Reviews, Admission HINN Reviews, and HINN-11 Reviews

NOTE: The terms “BIPA Review,” “Grijalva Review,” and “Weichardt Review” are for use only in QIO internal communication and in communication with CMS, other QIOs, and other QIO Program contractors.

BIPA Reviews Grijalva Reviews

Weichardt Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for Medicare Health Plan Enrollees

Hospital- Requested Reviews

Preadmission HINN Reviews and Admission HINN Reviews

HINN-11 Reviews

Context Fee-for-service

(FFS)

Managed care FFS Managed care FFS and managed care

FFS FFS

Who Can Request QIO review

FFS

beneficiary

Beneficiary’s representati ve

Medicare health plan enrollee receiving hospice benefits under FFS Medicare Part A

Medicare health plan enrollee

Enrollee’s representative

FFS beneficiary

Beneficiary’s representative

Medicare health plan enrollee

Enrollee’s representative

Hospital

For a Medicare health plan enrollee, the hospital is expected to consult with the Medicare health plan before requesting QIO review.

Review requests are accepted during the QIO’s normal business hours.

FFS

beneficiary

Beneficiary’s representative

FFS

beneficiary

Beneficiary’s representative

Medicare Appeals Council

Service(s) Medicare-covered

SNF

services

Hospital swing bed under Part A SNF-level services

Hospice

Medicare-covered SNF services

Hospital swing bed under Part A

Medicare-covered CORF services (if certification of

Inpatient hospital Inpatient hospital Inpatient hospital

Inpatient hospital

Inpatient hospital

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews under Part A (for both

FFS

beneficiaries and Medicare health plan enrollees), including hospice patients who dispute termination of hospice benefit

Medicare-covered

CORF

services (if certification of risk obtained)

Home health services under Part A or B and under a plan of care (if certification of risk obtained) risk obtained)

Home health services under Part A or B and under a plan of care st

Notice: Title and Form Number

Notice of Medicare Provider Non- Coverage

CMS-10123

Notice of Medicare Non- Coverage

CMS-10095-

NOMNC

An Important Message from Medicare about Your Rights

CMS-R-193

An Important Message from Medicare about Your Rights

CMS-R-193

Notice of Hospital- Requested Review

HINN-10

Preadmission Hospital-Issued Notice of Noncoverage:

Admission Hospital-Issued Notice of

HINN-11

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews

Noncoverage st

Notice:

Informal Name

Generic notice;

NOMPNC

Advance notice;

NOMNC

Important Message; IM

Important Message; IM

HINN-10 Preadmission HINN; Admission

HINN

HINN-11

Who Issues 1

Notice?

Provider Medicare health plan, or provider by delegation

Hospital Medicare health plan, or hospital by delegation

Hospital — Hospital

Timing of 1

Notice

Provider must issue generic notice no later than 2 calendar days before proposed end of services unless services have been terminated abruptly or services are expected to be shorter than 2 days in duration or span of time between services exceeds 2 days. If services expected to be less than 2 days in duration, notice must be given at time of admission. If span of time between

Plan or provider must issue advance notice no later than 2 calendar days before proposed end of services unless services have been terminated abruptly or services are expected to be shorter than 2 days in duration or span of time between services exceeds 2 days. If services expected to be less than 2 days in duration, notice must be given at time of admission. If span of time between services exceeds 2 days, notice must be given no later than the next-to-last time services are

Hospital must issue IM no later than 2 calendar days following admission, unless given at preadmission or pre-registration. If given at preadmission or pre-registration, must not be given more than 7 calendar days prior to admission and a follow-up IM must be given no later than 2 calendar days before planned date of discharge.

For abrupt or same-day discharges, hospital should issue IM at least 4 hours before discharge.

See §7340.2(B) re:

Plan or hospital must issue IM no later than 2 calendar days following admission, unless given at preadmission or pre-registration. If given at preadmission or pre-registration, must not be given more than 7 calendar days prior to admission and a follow-up IM must be given no later than 2 calendar days before planned date of discharge.

For abrupt or same-day discharges, hospital should issue IM at least 4 hours before discharge.

When hospital determines that patient no longer needs inpatient care but hospital is unable to obtain physician agreement.

QIO does not monitor timing of notice delivery.

Timing of admission HINN affects beneficiary liability.

QIO does not monitor timing of notice delivery.

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews services exceeds 2 days, notice must be given no later than the next-to-last time services are furnished.

furnished. discharges against medical advice.

See §7370.2(B) re: discharges against medical advice.

What to Do if 1

Notice Is Invalid

If error has potential to impact patient liability: QIO notifies provider and beneficiary/repr esentative of invalid notice and discontinues review unless new, valid notice is immediately issued and signed.

If error is not significant: QIO instructs provider to reissue notice but this does not delay the review process.

If error has potential to impact patient liability:

QIO notifies Medicare health plan, provider, and enrollee/represent ative of invalid notice and discontinues reviewunless new, valid notice is immediately issued and signed.

If error is not significant: QIO instructs provider to reissue notice but this does not delay the review process.

If error has potential to impact patient liability: QIO instructs hospital to reissue notice and to adjust planned discharge date if necessary; review discontinued unless new, valid notice is immediately issued and signed.

If error is not significant: QIO instructs hospital to reissue notice but this does not delay the review process.

If error has potential to impact patient liability:

QIO instructs plan/hospital to reissue notice and to adjust planned discharge date if necessary; review discontinued unless new, valid notice is immediately issued and signed.

If error is not significant: QIO instructs plan/hospital to reissue notice but this does not delay the review process.

nd

Notice: Title and Form Number

Detailed Explanation of Non-Coverage

Detailed Explanation of Non-Coverage

Detailed Notice of Discharge

CMS-10066

Detailed Notice of Discharge

CMS-10066

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews

CMS-10124 CMS-10095-

DENC

nd

Notice:

Informal Name

Detailed notice;

DENC

Detailed notice;

DENC

Detailed notice Detailed notice — — —

Who Issues 2 nd

Notice?

Provider Medicare health plan or provider by delegation

Hospital Medicare health plan or provider by delegation

Timing of 2

Notice

QIO’s normal close of business on day that QIO notifies provider that beneficiary/repr esentative has filed review request.

QIO’s normal close of business on day that QIO notifies Medicare health plan that enrollee/represent ative has filed review request.

See above and §7340.2(B) re:

follow-up copy of

IM.

Hospital must issue detailed notice no later than noon of the calendar day after the QIO notifies the hospital that beneficiary/represe ntative has filed review request.

See above and §7370.2(B) re:

follow-up copy of

IM.

Plan or hospital must issue detailed notice no later than noon of the calendar day after the QIO notifies plan/hospital that enrollee/represent ative has filed review request.

What to Do If nd Notice Is

Invalid

QIO continues review using available information.

QIO continues review using available information.

QIO continues review using available information.

QIO continues review using available information.

Deadline for Requesting QIO Review

Expedited review: noon of the calendar day preceding the effective date on the generic notice.

See §7120.2 for deadline when coverage

Noon of the calendar day preceding the effective date on the advance notice.

See §7220.2 for deadline when coverage ends abruptly.

Expedited review:

midnight of the planned discharge date.

Non-expedited review (untimely request) when beneficiary remains an inpatient: any time during the

Expedited review:

midnight of the planned discharge date.

No option for non-expedited QIO review.

Same as for IM Expedited review for Preadmission HINN: QIO’s normal close of business on the 3rd calendar day after the beneficiary received the HINN, including weekends and

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews ends abruptly.

Non-expedited review: within 60 days of effective date.

hospitalization.

Non-expedited review (untimely request) when beneficiary is no longer an inpatient:

30 calendar days after discharge, or at any time for good cause; see Appendix 7-2.

holidays

Expedited review for Admission HINN: Any point during the hospital stay

Non-expedited review: QIO’s normal close of business on the 30th calendar day after receipt of the

HINN

Is Certification of Risk Required?

For CORF or HHA, a physician (or NP or PA acting under physician’s direction) must certify that failure to continue service(s) may place the beneficiary’s health at significant risk.

Not required Not required Not required — — —

Who is Responsible for Providing Medical Records?

Provider Medicare health plan, or provider by delegation

Hospital Medicare health plan, or provider by delegation

Hospital Hospital Hospital

How to Deal with Missing, Incomplete, or

QIO issues technical denial to swing bed

QIO decides whether to proceed with

QIO issues technical denial.

QIO decides whether to proceed with

QIO decides whether to proceed with

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews

Illegible Medical Records provider; for other settings, QIO notifies Project Officer.

QIO decides whether to proceed with available information or defer review decision until additional information received, but deadline for QIO review decision does not change.

Provider may be financially liable if covered services continue past effective date;

see §7130.3.

available information or defer review decision until additional information received, but deadline for QIO review decision does not change.

Medicare health plan may be financially liable if covered services continue past effective date; see §7230.3.

QIO decides whether to proceed with available information or defer review decision until additional information received, but deadline for QIO review decision does not change.

Hospital may be financially liable if covered services continue past planned discharge date; see §7340.3.

available information or defer review decision until additional information received, but deadline for QIO review decision does not change.

Hospital may be financially liable if covered services continue past planned discharge date; see §7370.3.

available information or defer review decision until additional information received, but deadline for QIO review decision does not change.

Solicitation of Views

Provider uses detailed notice to explain termination/dis charge.

QIO interviews beneficiary/ representative.

QIO provides

Provider uses detailed notice to explain termination/discha rge.

QIO interviews enrollee/ representative.

QIO provides

Hospital uses detailed notice to explain discharge.

QIO interviews beneficiary/ representative.

QIO provides opportunity for hospital to explain

Medicare health plan or hospital by delegation uses detailed notice to explain discharge.

QIO interviews enrollee/ representative.

QIO provides

QIO interviews beneficiary/ representative.

QIO provides opportunity for hospital to explain why discharge is appropriate.

QIO interviews beneficiary/ representative.

QIO provides opportunity for hospital to explain why admission is not necessary.

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews opportunity for practitioner to explain why termination/ discharge is appropriate.

opportunity for practitioner to explain why termination/ discharge is appropriate.

why discharge is appropriate.

opportunity for plan/hospital to explain why discharge is appropriate.

Deadline for QIO Review Decision

Expedited review: 72 hours after receipt of review request (or 72 hours after receipt of physician certification if required).

Non-expedited review when beneficiary is still receiving services: QIO’s normal close of business on 7 th calendar day after QIO receives review request.

Non-expedited review when beneficiary is not still receiving services: QIO’s normal close of business on th calendar

QIO’s normal close of business on next calendar day after QIO receives all necessary information.

Expedited review:

QIO’s normal close of business on the next calendar day after QIO receives all necessary information.

Non-expedited review (untimely request) when beneficiary remains an inpatient: QIO’s normal close of business on the 2 calendar day after the QIO receives all necessary information.

Non-expedited review (untimely request) when beneficiary is no longer an inpatient:

QIO’s normal close of business on 30 th calendar day after QIO receives all necessary information.

Expedited review:

QIO’s normal close of business on the next calendar day after QIO receives all necessary information

No option for non-expedited review.

QIO’s normal close of business on the 2nd working day (Monday through Friday, excluding holidays) after the QIO receives both the review request and all necessary information from the hospital

Expedited review:

QIO’s normal close of business on 2nd working day (Monday through Friday, excluding holidays) after receipt of all information needed to complete the review

Non-expedited review: Written notification postmarked by QIO’s normal close of business on 30th calendar day after receipt of all information needed to complete the review (telephone notification not required)

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews day after QIO receives review request.

Whom to Notify of Review Decision

QIO notifies beneficiary/repr esentative, provider, and practitioner by phone, followed by written notice.

Non-appointed or non-authorized representative does not receive written notification and only receives review decision, information on liability, and information on reconsideration rights.

QIO notifies enrollee/represent ative, plan/provider by phone, followed by written notice.

Non-appointed or non-authorized representative does not receive written notification and only receives review decision, information on liability, and information on reconsideration rights.

QIO notifies beneficiary/represe ntative and hospital by phone, followed with written notice.

Non-appointed or non-authorized representative does not receive written notification and only receives review decision, information on liability, and information on reconsideration rights.

QIO notifies enrollee/represent ative, plan, and hospital by phone, followed by written notice.

Non-appointed or non-authorized representative does not receive written notification and only receives review decision, information on liability, and information on reconsideration rights.

QIO notifies beneficiary/enrolle e/representative, plan/provider by phone, followed by written notice.

QIO notifies beneficiary/repres entative and hospital by phone, followed by written notice.

Who Processes Reconsideratio n Reviews/Appeal s

QIC QIO Timely reconsideration request when beneficiary is still an inpatient: QIO.

Timely reconsideration request when beneficiary has been discharged:

Timely reconsideration request when enrollee is still an inpatient: QIO.

Timely reconsideration request when enrollee has been discharged: refer

Same as FFS Weichardt

Same as FFS Weichardt

Standard Medicare claims appeal process

Reviews for Fee-for-Service Beneficiaries

Weichardt Reviews for

Reviews

Preadmission HINN Reviews

Administrative Law Judge, Medicare Appeals Council, or federal court.

Untimely reconsideration request:

Administrative Law Judge, Medicare Appeals Council, or federal court.

enrollee to Medicare health plan for information on appeal rights.

Untimely reconsideration request: no reconsideration option.