Issuance of Hospital-Issued Notice of Non-coverage –

7005 - Issuance of Hospital-Issued Notice of Non-coverage – (Rev. 4, 07-18-03) A. Preadmission/Admission HINN The hospital issues a notice of non-coverage when it determines that the admission is not medically necessary, inappropriate, or custodial in nature. The hospital is not required to obtain concurrence from you or the attending physician prior to issuing the preadmission or admission notice of non-coverage. This also applies to HINNs related to direct admissions to swing beds (i.e., beneficiary is admitted to the swing bed after he/she was discharged from another hospital) and when the hospital determines that the beneficiary does not need SNF services. B. Continued-stay HINN A hospital may issue a continued-stay notice of non-coverage when it determines that a beneficiary no longer requires continued inpatient care and either the attending physician or you concur. Before a hospital can issue a continued-stay notice of non-coverage, it must consider the admission to be covered.  Attending Physician Concurs -- If the attending physician concurs in writing (e.g., written discharge order) with the hospital's determination that the beneficiary no longer requires inpatient care, the hospital may issue a notice of non-coverage to the beneficiary.  Attending Physician Does Not Concur -- The hospital is required to give a notice to the beneficiary or his/her representative when the beneficiary's physician disagrees with the hospital's proposed notice of non-coverage and you are requested to review the case (See Hospital Manual §414.11, Exhibit 10). The hospital may use its own letterhead, but it may not alter or change the language. The notice must be given to the beneficiary or his/her representative concurrently when the hospital requests your review. Develop procedures to monitor issuance of that notice to beneficiaries or their representatives. For example, at the time you solicit the beneficiary's views, ask the beneficiary or his/her representative if he/she received the notice. The hospital may request, either by phone or in writing, that you review the case immediately. Complete your review within 2 working days of either the hospital's request or receipt of any additional information you requested (such as copies of medical records). Determine, on a case-by-case basis, whether a medical record is needed to make the determination as to the medical necessity and appropriateness of the admission and days of care. If you concur with the hospital's decision, notify the hospital that it may issue its HINN and issue your denial notice. NOTE: In cases where the beneficiary requires a SNF level of care, the hospital cannot issue a notice of non-coverage if a SNF bed is not available. Medicare pays hospitals for days awaiting placement until a SNF bed is available, and the medical record documentation indicates that SNF placement is actively being sought.  Advance Continued-stay HINN -- The hospital could project and determine when acute care furnished to a beneficiary would end and issue a continued-stay notice of non-coverage (with concurrence from you or the attending physician). If a hospital is able to determine in advance that the beneficiary will not require acute inpatient hospital care as of a certain date, it may give the notice of non-coverage in advance of that date (but ordinarily no earlier than 3 days before the first non- covered day). EXAMPLE: The beneficiary had hip surgery, and he/she requires rehabilitative services but not at an acute hospital level of care. The hospital determines that the most appropriate setting for those services would be a SNF, and it makes arrangements to transfer the beneficiary (within 3 days) because a SNF bed will be available. EXAMPLE: The beneficiary is recovering from an uneventful post-surgical period after a cholecystectomy. The hospital can predict that within 2 days the beneficiary will no longer require injections for pain control and will tolerate a regular diet and ambulation. The advance notice does not relieve the hospital or the attending physician of the responsibility for monitoring the beneficiary's condition/level of care changes or for making appropriate discharge planning. If the beneficiary's condition/level of care changes after the notice is issued and further acute care is required (or the SNF bed is no longer available), then the hospital must rescind its notice of non-coverage. C. Combined Notices in Swing Bed Situations The "combined notice" applies to situations where the beneficiary is in an acute care hospital that has beds certified as swing beds, and he/she no longer requires an acute level of care. The discharge from the acute care bed and admission to the SNF or Nursing Facility (NF) swing bed is essentially a paper transaction with no physical movement of the beneficiary. The purpose of the combined notice is to notify the beneficiary or his/her representative that neither the acute nor SNF care is medically necessary or that the beneficiary no longer requires acute care hospital services but will begin to receive SNF swing bed services. The combined notice also notifies the beneficiary or his/her representative that if he/she disagrees with the hospital's decision an immediate QIO review may be requested (See §7015.B.1.b). The hospital must issue the combined notice of non-coverage with either the attending physician's or your concurrence. The two post-discharge planning days applicable to Prospective Payment System (PPS) hospital cases (See 42 CFR 412.42(c)) would not apply to this situation. The beneficiary's or his/her representative's liability for payment begins the day following the date of receipt of the notice. The beneficiary may request your immediate review; however, the beneficiary's liability remains the same as specified in the HINN. D. Continued-stay HINN in Swing Beds Treated as SNF Beds The hospital does not need the attending physician's or your concurrence to issue a continued-stay HINN to a beneficiary when SNF swing bed services are no longer needed. The immediate review provisions in §1154(e) of the Act do not apply to stays in SNF swing beds.