Notification of Denial - (Rev. 4, 07-18-03)

7105 - Notification of Denial - (Rev. 4, 07-18-03) Provide written notification of initial denials, technical denials, and DRG assignment changes to all affected parties, as appropriate (See Exhibits 7-22 through 7-34). A. Parties to be Notified - Provide Written Notice to:  The beneficiary or his/her representative. Do not notify the beneficiary or his/her representative of DRG assignment changes or denials based on circumvention of PPS or billing errors;  The attending physician or other attending health care practitioner. Do not notify the individual of circumvention of PPS denials. You are only required to notify the individual of changes to DRG coding information when the changes revise the DRG assignment;  The provider (if known, include in preadmission/pre-procedure cases). You and the provider are to specify in your memorandum of agreement who will receive your notices for the provider. You are only required to notify the provider of changes to DRG coding information when the changes revise the DRG assignment; and  The intermediary/carrier. If you notify the intermediary/carrier electronically of the denial determination (including limitation of liability determinations, if applicable), you need not provide a hardcopy of the notice. Notify the intermediary of DRG assignment changes. Do not notify the intermediary of coding changes that do not affect the DRG assignment. B. Issuance of Notice Issue notices on a case-by-case basis as follows:  One notice addressed to the beneficiary or his/her representative with copies to the provider, attending physician, and intermediary/carrier; or  One notice addressed to the provider (when the beneficiary or his/her representative is not notified) with copies to the attending physician and intermediary/carrier (Do not send a copy to the attending physician for circumvention of PPS denials). If a case is selected for retrospective review and you find that a HINN was issued, do not issue a denial notice if you agree with the provider's decision and the beneficiary was not liable for charges (Issue a notice for all HINN cases reviewed at the beneficiary's or provider's request). C. Determination of Beneficiary Address Ensure that denial notices mailed to beneficiaries who are no longer in the facility are sent to the correct address. To assist you in determining the beneficiary's correct address, CMS can provide you with copies of the Carrier Alphabetic State File (CASF) on microfilm or the Beneficiary Eligibility Status Tapes (BEST) on magnetic tape. Use of these files is optional. To obtain copies on an ongoing basis, send a written request to your RO project officer. There is no charge to you for these files.