Beneficiary Request for Review of Hospital-Issued Notice of Non-

7015 - Beneficiary Request for Review of Hospital-Issued Notice of Non- coverage by a QIO - (Rev. 4, 07-18-03) A. Preadmission/Admission HINN When a beneficiary or his/her representative requests review of a preadmission or admission HINN, review any records pertaining to health care services furnished. Include records pertaining to any inpatient hospital services provided or proposed to be provided to the Medicare beneficiary whether or not, in the hospital's view, the services are covered (See 42 CFR 476.88(a) and §§1154 and 1156 of the Act).  Immediate Review -- If the beneficiary or his/her representative disagrees with the hospital preadmission notice, he/she may request your review, by telephone or in writing, within 3 calendar days of receipt of the HINN. If admitted, the beneficiary or his/her representative may request your review at any point during the stay. In either situation review the case within 2 working days following the beneficiary's or his/her representative's request, and issue either a denial notice or a notice explaining that the care would be, or is, covered.  Review After Discharge or When Beneficiary Was Not Admitted to Hospital -- The beneficiary or his/her representative may request review within 30 calendar days after receipt of the notice. Complete this review within the timeframe specified for any retrospective review (See §4540). Once your review is completed issue either a denial notice or a notice explaining that the care is covered. B. Continued-stay HINN The beneficiary or his/her representative may request your review, as described below, when the hospital issues a continued-stay notice of non-coverage with the concurrence of the attending physician (see §7005.B.1). If the hospital issues a continued-stay notice of non-coverage with your concurrence, the beneficiary may request a reconsideration of your determination (see §7040).  Beneficiary Request for QIO Immediate Review of a HINN -- If the beneficiary or his/her representative disagrees with the HINN and remains in the hospital, he/she may request (not later than noon of the first working day after the day the notice was received) an immediate review by you. This request for review may be made by telephone or in writing. • The hospital must provide the medical records you require by close of business of the first working day after the date that the beneficiary receives the notice. Develop a procedure with the hospital that will ensure timely receipt of records (e.g., express mail service). • When a beneficiary or his/her representative requests your review, perform the review regardless of whether or not the hospital charges for continued-stay, or the beneficiary is liable for such care.  Prior to rendering a determination, solicit the views of the beneficiary or his/her representative, hospital, and attending physician (See §7020).  Complete the requested review and notify the beneficiary or his/her representative, the attending physician, and the hospital of your determination (whether adverse or favorable) within one full working day after the date of receiving the request and the required medical records. • Make your notification initially by telephone and follow up with a written notification either:  Disagreeing with the hospital's decision (i.e., notifying the beneficiary that he/she requires covered care); or  Agreeing with the hospital's determination (i.e., issuing your initial denial notice). In addition, the beneficiary will also receive the HINN. • Document the telephone notification (e.g., time of call, information presented, and names of parties contacted). Retain this documentation in your case files.  Other Review While the Beneficiary Is In the Hospital -- If the beneficiary or his/her representative does not request your review by noon of the first working day after receipt of the HINN and remains in the hospital, he/she may still request your review at any point during the stay. The request may be made by telephone or in writing. Review the case within 2 working days following the beneficiary's or his/her representative's request, and issue either a denial notice or a notice explaining that the care is covered.  Review After Discharge -- If the beneficiary is discharged from the hospital, he/she or his/her representative may still request review within 30 calendar days after receipt of the HINN or at any time, for good cause. Complete this review within 30 calendar days of receipt of the medical records, and issue either a denial notice or a notice explaining that the care is covered. NOTE: After a beneficiary has exhausted all of his/her hospital benefit days (and the length of stay has passed the day outlier threshold), you are not obligated to review the hospital's decision regarding the beneficiary's need for continued hospital care for those days. Any advisory determination you make related to these exhausted benefit days is not subject to your reconsideration process (and further appeal rights) as it is not an initial determination. Your initial determination pertaining to inpatient days prior to exhausting benefit days or within the outlier threshold is binding on all parties (i.e., you can approve or deny Medicare payment, but it is still subject to appeal by the beneficiary). C. Continued-stay HINN Rescinded -- If the hospital notifies you that the HINN has been rescinded after requesting the medical records:  Instruct the hospital to submit the medical records (including a copy of the notice rescinding the HINN);  Review the medical record and determine whether or not the hospital acted appropriately in rescinding the notice;  Notify the beneficiary that the HINN was rescinded if you agree with the hospital’s action and that he or she should have received a written notification from the hospital; and  Issue your written initial determination (including a determination of the beneficiary’s liability for payment under §1869 of the Act) if you disagree with the hospital’s rescinded HINN.