Judicial Review - (Rev. 4, 07-18-03)

7580 - Judicial Review - (Rev. 4, 07-18-03) A party may obtain judicial review of the Appeals Council's decision or a decision of an ALJ (when the request for review by the Appeals Council is denied) by filing a civil action under the Federal Rules of Civil Procedure within 60 calendar days after the date the party received notice of the ALJ's or Appeals Council's decision (See 42 CFR 405.730). If dissatisfied after ALJ or Appeals Council review:  A beneficiary can request judicial review on the issue of medical necessity/appropriateness of setting if the amount of the denied services is $2,000 or more;  A beneficiary, provider, or practitioner can request judicial review on the issue of knowledge (i.e., limitation on liability) if the amount of liability is $1,000 or more; or  A provider can request judicial review on the issue of circumvention of PPS (§1886(f)(2) of the Act) if the amount of the denied services is $1,000 or more (See §1869(b)(2)(A) of the Act and 42 CFR 405.730). Exhibit 7-20 - Limitation of Liability Model Paragraphs – (Rev. 4, 07-18-03) Summary of Limitation of Liability Conditions I-XIII: Identify the applicable limitation of liability condition (§1879 of the Act) and use the appropriate model paragraph. These paragraphs are not all-inclusive but are to be used as a guide in developing the appropriate language. Condition I: Use when beneficiary and provider are not liable under the limitation of liability provision of the law. Condition II: Use when beneficiary is not liable, and the provider is liable under the limitation of liability provision of the law. Use for all denials for custodial or medically unnecessary services/(level of) care. Condition III: Use when beneficiary is not liable, and the provider and the Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Beneficiary is not responsible for payment of deductible/coinsurance. Use for medically unnecessary procedure(s) and cost outlier(s) with physician component denials (See Exhibits 7-28 and 7-30). Condition IIIA: Use when beneficiary is not liable, but the provider is liable under the limitation of liability provision of the law, and the nonparticipating physician who furnished services on an unassigned basis is liable (for a refund of any amount paid) under §1842(l) of the Act. Use for medically unnecessary procedure(s) and cost outlier(s) with physician component denials (See Exhibits 7-28 and 7-30). Condition IV: Use when beneficiary is liable, and the provider is not liable under the limitation of liability provision of the law (e.g., beneficiary had received prior notice for non-covered services proposed/furnished by a provider, and the patient received, from a different provider, the denied services which involve the same or reasonably comparable conditions). Condition V: Use when beneficiary and provider are liable under the limitation of liability provision of the law (e.g., provider and beneficiary had received prior notice for the same or reasonably comparable non-covered services). Condition VI: Use when beneficiary is not liable (until date specified by you), and the provider is liable under the limitation of liability provision of the law. Use for denials based on a provider's request for review of a proposed continued-stay HINN (See Exhibit 7-27, Condition I), or a beneficiary's request for non-immediate review of a continued- stay HINN, or a beneficiary's request for review of a SNF swing bed continued-stay HINN (See Exhibit 7-27, Condition II). This applies to both PPS and non-PPS hospitals. Condition VII: Use when beneficiary is not liable (until noon of the day specified by you), and the provider is liable under the limitation of liability provision of the law. Use for denials based on a beneficiary's request for an immediate review of a continued-stay HINN (See Exhibit 7-27, Condition II). This applies to both PPS and non-PPS hospitals (It does not apply to SNF swing bed continued-stay denials. See Condition VI). Condition VIII: Use when beneficiary and provider are not liable under the limitation of liability provision of the law. Use for concurrent review of continued-stay denials not involving a HINN where you are approving payment for additional days for purposes of post-discharge planning (i.e., grace days) (See Exhibit 7-27, Condition VII). This applies to both PPS and non-PPS hospitals. Condition IX: Use when beneficiary and provider are both not liable for part of the denied period and liable for part of the denied period. Use when the beneficiary is responsible for payment of any deductible, coinsurance, and convenience services and items furnished during the covered admission. Condition X: Use when beneficiary is not liable for a part of the denied period and liable for a part of the denied period, and the provider is liable for the entire denied period. Use when the beneficiary is not responsible for payment of the denied services, including any deductible and coinsurance, for part of the denied period and is responsible for payment for the denied services, including any deductible and coinsurance, for another part of the denied period. Condition XI: Use when beneficiary, provider, and Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are not liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II). For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA. Condition XII: Use when beneficiary is not liable. The provider and the Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II). For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA. Condition XIII: Use when beneficiary, provider, and Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II). For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA. NOTE: For denials of inpatient hospital services furnished on or after January 1, 1989, through December 31, 1989, delete reference to the beneficiary's responsibility for coinsurance payment for Conditions I, II (partial denials), III (partial denials), VI, VII, VIII, IX, and X (partial denials) (Does not apply to services/items furnished in SNF swing beds). For denials of SNF swing bed services/items, do not make reference to deductibles, as deductibles do not apply to SNF swing bed denials. Limitation of Liability Model Paragraphs: Condition I: Use when beneficiary and provider are not liable under the limitation of liability provision of the law: We have also determined that neither you nor the hospital knew that the denied services were not covered under Medicare. Medicare will, therefore, pay the hospital for the services under a provision of the Social Security Act. You are responsible only for payment of any amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare furnished during this admission. If you have paid the hospital for any denied services other than those amounts already mentioned, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. Condition II: Use when beneficiary is not liable, and the provider is liable under the limitation of liability provision of the law. Use for all denials for custodial or medically unnecessary services/(level of) care: We have also determined that you did not know that the denied services were not covered under Medicare. Medicare will not pay the hospital for the denied services because the hospital knew or should have known that the services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). If you have paid the hospital for any denied services other than those amounts already mentioned, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. For total denials, insert: "You are not responsible for payment for the denied services, including any applicable deductible and coinsurance, except for any amounts for convenience services and items normally not covered by Medicare." For partial denials, insert: "You are not responsible for payment for the services which were denied, except for any applicable amounts for deductible and coinsurance related to the services found covered, plus any amounts for convenience services and items normally not covered by Medicare." Condition III: Use when beneficiary is not liable, and the provider and the Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Beneficiary is not responsible for payment of deductible/coinsurance. Use for medically unnecessary procedure(s) and cost outlier(s) with physician component denials (See Exhibits 7-28 and 7-30): We have also determined that you did not know that the denied services were not covered under Medicare. Medicare will not pay the hospital for the denied services because the hospital knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). In addition, Medicare will not pay for any of your physician's services related to this denial because your physician knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). If you have paid the hospital or your physician for any denied services other than those amounts already mentioned, arrangements can be made to pay you back. For refund of payment related to hospital services, please contact the Fiscal Intermediary (FI). For refund of payment related to physician services, please contact the carrier at: FI or Carrier Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI or carrier with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. For total denials, insert: "You are not responsible for payment for the denied services, including any applicable deductible and coinsurance, except for any amounts for convenience services and items normally not covered by Medicare." For partial denials, insert: "You are not responsible for payment for the services which were denied, except for any applicable amounts for deductible and coinsurance related to the services found covered, plus any amounts for convenience services and items normally not covered by Medicare." Condition IIIA: Use when beneficiary is not liable, but the provider is liable under the limitation of liability provision of the law, and the nonparticipating physician who furnished services on an unassigned basis is liable (for a refund of any amount paid) under §1842(l) of the Act. Use for medically unnecessary procedure(s) and cost outlier(s) with physician component denials (See Exhibits 7-28 and 7-30): We have also determined that you did not know that the denied services were not covered under Medicare. Medicare will not pay the hospital for the denied services because the hospital knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). If you have paid the hospital for any of the denied services other than those amounts already mentioned, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number In addition, we determined that your physician knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Therefore, Medicare will not pay you for any of your physician's services related to this denial. However, you are not responsible for payment for your physician's services because your physician did not notify you, in writing, that his/her services would not be covered under Medicare. You are entitled to a refund if you have paid your physician for any of the denied services. You should contact your physician for any refund. If you have difficulty obtaining this refund, you should contact the carrier at: Carrier Name Address Telephone Number For total denials, insert: "You are not responsible for payment for the denied services, including any applicable deductible and coinsurance, except for any amounts for convenience services and items normally not covered by Medicare." For partial denials, insert: "You are not responsible for payment for the services which were denied, except for any applicable amounts for deductible and coinsurance related to the services found covered, plus any amounts for convenience services and items normally not covered by Medicare." You must make your written request for payment within 6 months of the date of this notice and provide the FI or carrier with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. NOTE: When you determine that the nonparticipating physician did not know that the denied services would not be covered under Medicare, or if the nonparticipating physician gives the beneficiary or his/her representative a written notice explaining that the services will not be covered under Medicare, the beneficiary is responsible for payment for the denied physician services (i.e., the beneficiary is not entitled to a refund. In these instances, use the following language as applicable:  "We have determined that your physician did not know that the services denied would not be covered under Medicare. Since your physician does not accept Medicare assignment, Medicare cannot pay you for any of your physician's services related to this denial. Therefore, you are responsible for payment for his/her services." • OR  "We have determined that you knew that your physician's services would not be covered under Medicare based on the written notification he/she gave to you on (date of written notice), a copy of which is enclosed. Medicare will not pay you for any of your physician's services related to this denial. Therefore, you are responsible for payment for his/her services." Condition IV: Use when beneficiary is liable, and the provider is not liable under the limitation of liability provision of the law (e.g., beneficiary had received prior notice for non-covered services proposed/furnished by a provider, and received, from a different provider, the denied services which involve the same or reasonably comparable conditions): We have also determined that you knew or should have known that the denied services were not covered under Medicare based on prior notification sent to you on (date of prior notice), a copy of which is enclosed. Therefore, Medicare will not pay the hospital for the denied services even though we have determined that the hospital did not know that these services are not covered. You are responsible for payment of all costs for the denied hospital services you received except for those covered services which can be paid for by Medicare Part B. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. Condition V: Use when beneficiary and provider are liable under the limitation of liability provision of the law (e.g., provider and beneficiary had received prior notice for the same or reasonably comparable non-covered services): We have also determined that you knew or should have known that the denied services were not covered under Medicare based on prior notification sent to you on (date of prior notice), a copy of which is enclosed. The hospital knew or should have known based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Therefore, Medicare will not pay the hospital for the denied services. You are responsible for payment of all costs for the denied hospital services you received except for those covered services which can be paid for by Medicare Part B. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. For partial denials, insert: "In addition, you are responsible for payment of any amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare furnished during this admission." Condition VI: Use when beneficiary is not liable (until date specified by you), and the provider is liable under the limitation of liability provision of the law. Use for denials based on a provider's request for review of a proposed continued-stay HINN (See Exhibit 7-27, Condition I), a beneficiary's request for non-immediate review of a continued-stay HINN, or a beneficiary's request for review of a SNF swing bed continued-stay HINN (see Exhibit 7-27, Condition II). This applies to both PPS and non-PPS hospitals: We notified you by telephone on (date of telephone notification) of our determination that the services you are receiving are not covered by Medicare and that if you decided to remain in the hospital, beginning on (date), you would be responsible for payment of all costs for hospital services you receive except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to (date), you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and the hospital of this denial. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. For PPS hospitals or hospitals participating in State payment control systems or demonstration projects, insert the date of the third day following the date of receipt of the HINN. For non-PPS hospitals, PPS exempt units, and SNF swing beds, insert the date of the day following the date of receipt of the HINN. Condition VII: Use when beneficiary is not liable (until noon of the day specified by you), and the provider is liable under the limitation of liability provision of the law. Use for denials based on a beneficiary's request for an immediate review of a continued-stay HINN (See Exhibit 7-27, Condition II). This applies to both PPS and non-PPS hospitals. It does not apply to SNF swing bed continued-stay denials (See Condition VI): We notified you by telephone on (date of telephone notification) of our determination that the services you are receiving are not covered by Medicare and that if you decided to remain in the hospital after 12 noon on (day following date of your telephone notification), you would be responsible for payment of all costs of hospital services you receive after that time except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to 12 Noon on (day following date of your telephone notification), you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and hospital of this denial. You should discuss other arrangements for any further health care you may now require with your physician. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Condition VIII: Use when beneficiary and provider are not liable under the limitation of liability provision of the law. Use for concurrent review of continued-stay denials not involving a HINN where you are approving payment for additional days for the purpose of post-discharge planning (i.e., grace days) (See Exhibit 7-27, Condition VII). This applies to both PPS and non-PPS hospitals: We have also determined that neither you nor the hospital knew that the denied services would no longer be covered under Medicare beginning (date of first non-covered day). Therefore, under a provision of the Social Security Act, Medicare will pay for (select number of days up to 2) additional day(s) from the date of this notice to arrange for your post-discharge care. If you decide to remain in the hospital beginning on (2nd or 3rd day from date of notice), you will be responsible for payment of all costs of hospital services you receive except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to (2nd or 3rd day from date of notice), you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and hospital of this denial. You should discuss other arrangements for any further health care you may now require with your physician. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. Please be aware that Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Condition IX: Use when beneficiary and provider are both not liable for part of the denied period and liable for part of the denied period. Use when the beneficiary is responsible for payment of any deductible, coinsurance, and convenience services and items applicable to the covered admission: We have determined that neither you nor the hospital knew that the denied services from (specify the date(s) not liable) were not covered under Medicare. Medicare will, therefore, pay the hospital for the denied services for this period under a provision of the Social Security Act. We have also determined that you and the hospital knew or should have known that the denied services from (specify the date(s) liable) were not covered under Medicare. You knew or should have known based on a prior notification sent to you on (date of prior notice), a copy of which is enclosed. The hospital knew or should have known based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Medicare will not pay the hospital for the denied services for this period. You are responsible for payment of all costs of the denied hospital services you received from (specify the date(s) liable) except for those covered services which can be paid for by Medicare Part B. In addition, you are responsible for payment of any amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare which are applicable to this admission. If you have paid the hospital for any of the denied services from (specify the date(s) not liable), other than any applicable amounts for deductible, coinsurance, and convenience services and items, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. Condition X: Use when beneficiary is not liable for a part of the denied period and liable for a part of the denied period, and the provider is liable for the entire denied period. Use when the beneficiary is not responsible for payment for the denied services, including any deductible and coinsurance, for part of the denied period and is responsible for payment of the denied services, including any deductible and coinsurance, for another part of the denied period: We have determined that you did not know that the denied services from (specify the date(s) not liable) were not covered under Medicare. We have also determined that you knew or should have known that the denied services from (specify the date(s) liable) were not covered under Medicare based on a prior notification sent to you on (date of prior notice), a copy of which is enclosed. The hospital knew or should have known that the denied services from (specify the date(s) denied) were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Therefore, Medicare will not pay the hospital for the denied services. You are not responsible for payment of the denied services from (specify the date(s) not liable) except for any amounts for convenience services and items normally not covered by Medicare. You are responsible for payment of all costs for the denied hospital services you received from (specify the date(s) liable) except for those covered services which can be paid for by Medicare Part B. If you have paid the hospital for any of the denied services from (specify the date(s) not liable) other than any amounts for convenience services and items, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. Condition XI: Use when beneficiary, provider, and Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are not liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II) (For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA): We have also determined that you, the provider, and your physician did not know that the denied services were not covered under Medicare. Medicare will, therefore, pay the provider and your physician for the denied services under a provision of the Social Security Act. You are responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare (e.g., telephone and television charges). If you have paid the provider or your physician for any of the denied services other than those amounts already mentioned, arrangements can be made to pay you back. You must make your written request for payment within 6 months of the date of this notice and provide the FI and/or carrier with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. For ambulatory surgical center settings insert: "Please contact the carrier at:" Carrier Name Address Telephone Number For hospital outpatient settings insert: “For refund of payment related to hospital services, please contact the Fiscal Intermediary (FI) at:” FI Name Address Telephone Number For hospital outpatient settings insert: “For refund of payment related to physician services, please contact the carrier at:” Carrier Name Address Telephone Number Condition XII: Use when beneficiary is not liable. The provider and the Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II) (For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA): We have also determined that you did not know that the denied services were not covered under Medicare. Medicare will not pay the provider for the denied services because the provider knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). In addition, Medicare will not pay for any of the physician's services related to this denial because your physician knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). You are not responsible for payment for the denied services except for any amounts for convenience services and items normally not covered by Medicare (e.g., telephone and television charges). If you have paid the provider or your physician for any of the denied services other than those amounts already mentioned, arrangements can be made to pay you back. You must make your written request for payment within 6 months of the date of this notice and provide the FI and/or carrier with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. For ambulatory surgical center settings insert: "Please contact the carrier at:" Carrier Name Address Telephone Number For hospital outpatient settings insert: “For refund of payment related to hospital services, please contact the Fiscal Intermediary (FI) at:” FI Name Address Telephone Number For hospital outpatient settings insert: “For refund of payment related to physician services, please contact the carrier at:” Carrier Name Address Telephone Number Condition XIII: Use when beneficiary, provider, and Medicare participating physician (or nonparticipating physician who furnished services on an assigned basis) are liable under the limitation of liability provision of the law. Use for outpatient/ambulatory surgical denials (See Exhibit 7-32, Condition II) (For denials involving nonparticipating physicians who furnished services on an unassigned basis, see language under Condition IIIA): We have also determined that you knew or should have known that the denied services were not covered under Medicare based on a prior notification sent to you on (date of prior denial notice from any QIG, FI/carrier, physician, or provider), a copy of which is enclosed. The provider knew or should have known that the denied services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Your physician knew or should have known that the services were not covered under Medicare based on (specify: brochures, prior notices (including dates), manual references, criteria, etc.). Therefore, Medicare will not pay the provider or your physician for the denied services. You are responsible for payment of all costs for the denied services you received including any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare (e.g., telephone and television charges). Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate care you may require in the future. Should the need arise, we encourage you to discuss arrangements for your health care with your physician. Exhibit 7-21 - Reconsideration Model Paragraphs - (Rev. 4, 07-18-03) Summary of Reconsideration Conditions I-III: Identify the applicable reconsideration condition, and use that model paragraph. Condition I: Use for preadmission denials (i.e., the patient is not yet admitted to the hospital). Condition II: Use for concurrent denials (i.e., the patient is still in the hospital). Condition III: Use for retrospective denials (i.e., the patient has been discharged from the hospital). Reconsideration Model Paragraphs: Condition I: Use for preadmission denials (i.e., the patient is not yet admitted to the hospital): If you, your physician, or hospital disagrees with our determination, you may appeal this denial decision by requesting an expedited reconsideration by telephone or in writing. You must make your request for an expedited reconsideration within 3 calendar days from the date of this notice directly to us at: QIO Name Address Telephone Number We will complete our expedited reconsideration and send a written notice to you within 3 working days. However, if you do not wish an expedited reconsideration, you, your physician, or hospital are still entitled to a reconsideration. You must submit your request in writing within 60 calendar days from the receipt of this notice to us at the above address. You may also make your request to any Social Security Office or Railroad Retirement Office (if you are a Railroad Retirement beneficiary). Your request will be forwarded to us. As a result of our review, we may reaffirm or reverse our prior denial determination. If we reaffirm the denial determination, you will continue to be responsible for payment of services furnished as specified above. If we reverse the denial determination, you will be refunded any amount collected by the hospital except for payment of deductible, coinsurance, or any convenience services or items normally not covered by Medicare. Condition II: Use for concurrent denials (i.e., the patient is still in the hospital): If you disagree with our determination and you decide to remain in the hospital, you, your physician, or hospital may appeal this denial decision while you are still in the hospital by requesting an expedited reconsideration through the hospital or by telephoning or writing us at: QIO Name Address Telephone Number We will complete our expedited reconsideration and send a written notice to you within 3 working days. However, if you do not remain in the hospital after (date liability begins), or if you remain in the hospital and do not request an expedited reconsideration, you, your physician, or hospital are still entitled to a reconsideration. You must submit your request in writing within 60 calendar days from receipt of this notice to us at the above address. You may also make your request to any Social Security Office or Railroad Retirement Office (if you are a Railroad Retirement beneficiary). Your request will be forwarded to us. As a result of our review, we may reaffirm or reverse our prior denial determination. If we reaffirm the denial determination, you will continue to be responsible for payment of services furnished as specified above. If we reverse the denial determination, you will be refunded any amount collected by the hospital except for payment of deductible, coinsurance, or any convenience services or items normally not covered by Medicare. Condition III: Use for retrospective denials (i.e., the patient has been discharged from the hospital): If you, your physician, or hospital disagrees with our determination, you may appeal this denial decision by requesting a reconsideration. You must submit your request in writing within 60 calendar days from receipt of this notice directly to us at: QIO Name Address Telephone Number You may also make your request to any Social Security Office or Railroad Retirement Office (if you are a Railroad Retirement beneficiary). Your request will be forwarded to us. As a result of our review, we may reaffirm or reverse our prior denial determination. If we reaffirm the denial determination, you will continue to be responsible for payment of services furnished as specified above. If we reverse the denial determination, you will be refunded any amount collected by the hospital except for payment of deductible, coinsurance, or any convenience services or items normally not covered by Medicare. Exhibit 7-23 - Record Not Submitted Timely Denial Model Notice - (Rev. 4, 07-18-03) Use for retrospective admission denials when the medical record (or itemized bill for cost outliers) is not submitted timely by the hospital.  Opportunity for discussion does not apply.  Limitation of liability (§1879 of the Act) does not apply.  Reconsideration does not apply. NOTE: For inpatient hospital services furnished on or after January 1, 1989, through December 31, 1989, delete reference to the beneficiary's:  Responsibility for payment of the coinsurance; and  Utilization of the benefit period. Record Not Submitted Timely Denial Model Notice: YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. We have denied Medicare payment for your admission of (date) to (provider name) for (specify the procedure/treatment or condition/services). This denial is due solely to the hospital's failure to submit your (select: medical record; or itemized bill; or medical record and itemized bill) as requested by us. This information is necessary for us to complete review of this claim. Medicare will not pay the hospital for this admission. However, you are not responsible for payment of the denied services except for any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. If you have paid the hospital for any of the denied services other than those amounts just mentioned, arrangements can be made to pay you back. Please contact the Fiscal Intermediary (FI) at: FI Name Address Telephone Number You must make your written request for payment within 6 months of the date of this notice and provide the FI with the following documents:  A copy of this notice;  The bill you received for the services; and  The payment receipt or any other evidence (e.g., canceled check) showing that you have paid for the denied services. Be aware that the days you spent as an inpatient will be subtracted from the total number of days available to you in this benefit period. Your case can be reopened when the necessary information is submitted by the hospital. You will be notified of the decision resulting from this review. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-24 - Billing Error Denial Model Notice - (Rev. 4, 07-18-03) Use for retrospective admission denials when review cannot be completed due to a provider billing error (e.g., incorrectly billed an uninterrupted stay as two separate admissions). Use this notice if you are responsible for notification of billing errors as a result of your agreements with the FI(s) and provider.  Opportunity for discussion does not apply.  Limitation of liability (§1879 of the Act) does not apply.  Reconsideration does not apply.  Do not notify the beneficiary. NOTE: For inpatient hospital services furnished on or after January 1, 1989, through December 31, 1989, delete reference to the beneficiary's responsibility for payment of the coinsurance. Billing Error Denial Model Notice: YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. We have denied Medicare payment for the above admission of (date) for (specify the procedure/treatment or condition/services). In reviewing this admission, an error in billing was discovered which precludes us from completing review of this claim. Our determination is based on the following: (Relate discussion to specific billing error). Medicare will not pay the hospital for this admission. The beneficiary or his/her representative is only responsible for payment for any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. This case can be reopened when a corrected bill is submitted by the hospital to the Fiscal Intermediary (FI), at which time the FI will resubmit the case to us to complete review. Sincerely, Medical Director (or designated physician) Chief Executive Officer, etc., as appropriate ccs: Hospital Physician FI Carrier Exhibit 7-25 - Preadmission Denial Model Notice - (Rev. 4, 07-18-03) Use only for denials of services furnished prior to admission to the facility.  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) does not apply.  Reconsideration applies (See Exhibit 7-21). Preadmission Denial Model Notice: YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physician reviewers have denied Medicare payment for your proposed admission of (date) (specify, if known: "to" (name of provider)) for (specify the procedure/treatment or condition/services). Prior to reaching this decision, we gave your physician (if known: and the hospital) an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a full discussion of the specific reason(s) for denial). Medicare will not pay for your proposed admission if you and your physician decide you should be admitted to the hospital. We are also advising your physician (if known: and the hospital) of this denial. You should discuss with your physician other arrangements for any further health care you may now require. NOTE: For denials of provider services only, insert: “Therefore, you will be responsible for payment of all costs for the hospital services you receive except for those covered services which can be paid for by Medicare Part B.” NOTE: For denials of provider and related physician services, insert: "Therefore, you will be responsible for payment of all costs for the hospital and related physician services you receive except for those covered services which can be paid for by Medicare Part B." Upon receipt of this notice, you will continue to be responsible for payment of denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. Use reconsideration paragraph under Condition I. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-26 - Admission Denial Model Notices - (Rev. 4, 07-18-03) Identify the denial condition, and use the appropriate model notice. Condition I: Use for retrospective admission denials (PPS and non-PPS hospitals) based on inappropriate setting, medically unnecessary, or custodial care. Revise accordingly for denials involving direct admission for NF swing bed services with or without an admission HINN. Condition II: Use for retrospective denials based on inappropriate setting, medically unnecessary, or custodial care involving "deemed" admission date cases. For both conditions:  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Admission Denial Model Notices: Condition I: Use for retrospective admission denials (PPS and non-PPS hospitals) based on inappropriate setting, medically unnecessary, or custodial care. Revise accordingly for denials involving direct admission for swing bed services with or without an admission HINN. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physician reviewers have denied Medicare payment for your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under Condition I, II, III, IV, V, IX, or X. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition II: Use for retrospective denials based on inappropriate setting, medically unnecessary, or custodial care involving "deemed" admission date cases. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We have determined that the services you received from (date) through (date) are denied for Medicare payment. We have also determined that the services you received for (specify the procedure/treatment or condition/services) beginning (date) were medically necessary and appropriate. Therefore, Medicare will pay for hospital services from (date) through (date). Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under Condition I, II, III, IV, V, IX, or X. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-27 - Continued-stay Denial Notices - (Rev. 4, 07-18-03) Summary of Continued-stay Denial Notices Conditions I-VIII: Identify the denial condition, and use the appropriate model notice. Condition I: Use for concurrent denials when the provider requests review of a proposed continued-stay HINN. Condition II: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a continued-stay HINN (includes SNF swing bed continued- stay denials). Condition III: Use for concurrent denials when the provider requests review of a proposed combined HINN (i.e., acute care continued-stay denial involving NF swing bed services). Condition IV: Use for concurrent denials when the provider requests review of a proposed combined HINN (i.e., acute care continued-stay denial involving SNF swing bed services). Condition V: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a combined HINN (i.e., acute care continued-stay denial involving NF swing bed services). Condition VI: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a combined HINN (i.e., acute care continued-stay denial involving SNF swing bed services). Condition VII: Use for concurrent denials not involving a continued-stay HINN. Condition VIII: Use for retrospective denials with or without a continued-stay HINN (For PPS cases without a continued-stay HINN, this condition only applies to denials involving the day outlier period of the stay). For all conditions:  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Continued-stay Denial Model Notices: Condition I: Use for concurrent denials when the provider requests review of a proposed continued-stay HINN. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Based on (name of provider)'s request, our physicians have reviewed your admission on (date) for (specify the procedure/treatment or condition/services). We have determined that your admission was medically necessary and appropriate. However, the services you are currently receiving are not covered by Medicare. Therefore, any inpatient hospital services you receive beginning (date) will not be paid by Medicare. Prior to reaching this decision, we considered the information provided through a telephone discussion with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Use limitation of liability paragraph in Exhibit 7-20 under Condition VI. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition II: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a continued-stay HINN (includes SNF swing bed continued- stay denials). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. On (date of request for review of HINN), you requested that we review your case because you received, with your physician's concurrence, a notice of non-coverage from (name of provider) on (date). Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We have determined that your admission was medically necessary and appropriate. We agree, however, with your physician and the hospital that for the reasons specified below, as of (date specified by QIO under Condition VI or VII of limitation of liability paragraph), the services you are currently receiving are not covered by Medicare because (reason for denial). Therefore, any inpatient hospital services you receive beginning (date specified by QIO under Condition VI or VII of limitation of liability paragraph) will not be paid by Medicare. Prior to reaching this decision, we considered the information provided through telephone discussions with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select limitation of liability paragraph in Exhibit 7-20 under Condition VI or VII. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition III: Use for concurrent denials when the provider requests review of a proposed combined HINN (i.e., acute care continued-stay denial involving NF swing bed services). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Based on (name of provider)'s request, our physicians have reviewed your admission for acute care services on (date) for (specify the procedure/treatment or condition/services). We have determined that your admission for acute care services was medically necessary and appropriate but that you no longer require acute care services beginning (date of first non-covered acute care day). The care that you need now is not covered by Medicare. Therefore, any inpatient hospital services you receive beginning (date) will not be paid by Medicare. Prior to reaching this decision, we considered the information provided through a telephone discussion with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). We notified you on (date of (telephone) notification) that beginning on (date of the day following the date of receipt of the QIO notification) you would be responsible for payment of all costs for hospital services you receive except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to (date of the day following the date of receipt of the QIO notification), you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and hospital of this denial. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment for denied acute care services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate acute hospital care you may require in the future. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition IV: Use for concurrent denials when the provider requests review of a proposed combined HINN (i.e., acute care continued-stay denial involving SNF swing bed services). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Based on (name of provider)'s request, our physicians have reviewed your admission on (date) for (specify the procedure/treatment or condition/services). We have determined that your admission for acute care services was medically necessary and appropriate, but that you no longer require acute care services beginning (date of first non-covered acute care day). However, we have determined that you still require the type of hospital services which are furnished in a Skilled Nursing Facility (SNF) beginning (specify date of first SNF swing bed day). These services are known as SNF swing bed services. Medicare will pay for your SNF swing bed services if you have not used up all your SNF benefit days. Prior to reaching this decision, we considered the information provided through a telephone discussion with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). We notified you on (date of (telephone) notification) of our determination that you no longer required acute care services, but that you do still require SNF services. Therefore, you are responsible only for payment of any amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare applicable to the acute care and SNF services received during your entire hospital stay. We are also advising your physician and hospital of this determination. Upon receipt of this notice, you will be responsible for payment for denied acute care services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate acute hospital care you may require in the future. Should the need arise for further acute care, we encourage you to discuss arrangements for your health care with your physician. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition V: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a combined HINN (i.e., acute care continued-stay denial involving NF swing bed services). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. On (date of request for review of HINN), you requested that we review your case because you received a notice of non-coverage from (name of provider) on (date), and you believe you still require acute care services. Our physicians have reviewed your admission of (date of acute care admission) for (specify the procedure/treatment or condition/services). We have determined that your admission for acute care services was medically necessary and appropriate but that you no longer require acute care services beginning (date of first non-covered acute care day). The care that you need now is not covered by Medicare. Therefore, any inpatient hospital services you receive beginning (date) will not be paid by Medicare. Prior to reaching this decision, we considered the information provided through a telephone discussion with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). We notified you on (date of (telephone) notification) that beginning on (date of the day following the date of receipt of the HINN) you would be responsible for payment of all costs for hospital services you receive except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to (date of the day following the date of receipt of the HINN), you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and hospital of this denial. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment of denied acute care services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate acute hospital care you may require in the future. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition VI: Use for concurrent denials when the beneficiary requests an immediate or non-immediate review of a combined HINN (i.e., acute care continued-stay denial involving SNF swing bed services). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. On (date of request for review of HINN), you requested that we review your case because you received a notice of non-coverage from (name of provider) on (date), and you believe you still require acute care services. Our physicians have reviewed your admission of (date of acute care admission) for (specify the acute care procedure/treatment or condition/services). We have determined that your admission for acute care services was medically necessary and appropriate, but that you no longer required acute care services beginning (date of first non-covered acute care day). However, we have determined that you still require the type of hospital services which are furnished in a Skilled Nursing Facility (SNF) beginning (specify date of first SNF swing bed day). These services are known as SNF swing bed services. Medicare will pay for your SNF swing bed services if you have not used up all your SNF benefit days. Prior to reaching this decision, we considered the information provided through a telephone discussion with (insert either "you" or the name of the representative to whom you spoke) on (date of solicitation of views), and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). We notified you on (date of (telephone) notification) of our determination that you no longer require acute care services, but that you do still require SNF services. Therefore, you are responsible only for payment of any amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare applicable to the acute care and SNF services received during your entire hospital stay. We are also advising your physician and hospital of this determination. Upon receipt of this notice, you will be responsible for payment for denied acute care services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate acute hospital care you may require in the future. Should the need arise for further acute care, we encourage you to discuss arrangements for your health care with your physician. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition VII: Use for concurrent denials not involving a continued-stay HINN. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We have determined that your admission was medically necessary and appropriate. However, the services you are currently receiving are not covered by Medicare. Therefore, any inpatient hospital services you receive beginning (date) will not be paid by Medicare. Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Use limitation of liability paragraph in Exhibit 7-20 under Condition VIII. Use reconsideration paragraph in Exhibit 7-21 under Condition II. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition VIII: Use for retrospective denials with or without a continued-stay HINN (For PPS cases without a continued-stay HINN, this condition only applies to denials involving the day outlier period of the stay). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We have determined that your admission was medically necessary and appropriate. However, the inpatient hospital services you received beginning (specify denied date(s)) are denied for Medicare payment. Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under Condition I, II, III, IV, V, IX, or X. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-28 - Procedure Denial Model Notices - (Rev. 4, 07-18-03) Identify the denial condition, and use the appropriate model notice. Condition I: Use for retrospective procedure denials. If the beneficiary required hospital inpatient services but the procedure is not medically necessary, then only the procedure is denied. Use the procedure denial model notice.  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Condition II: Use for preadmission denials. If the proposed procedure is non-covered and is the only reason for the admission, then the admission is denied. Use the preadmission denial model notice (See Exhibit 7-25). Condition III: Use for retrospective admission denials. If the procedure is non-covered and is the only reason for the admission, then the admission is denied. Use the admission denial model notice (See Exhibit 7-26, Condition I). Condition IV: Use for concurrent or retrospective continued-stay denials. If the beneficiary required admission initially, but remain(s/ed) in the facility for the proposed procedure only, then the continued-stay is non-covered and is denied. Use the appropriate continued-stay denial model notice (See Exhibit 7-27). NOTE: For any of the above conditions, if the denial is for a procedure that cannot be repeated (e.g., total removal of an organ), do not use the future liability paragraph: "Upon receipt..." Procedure Denial Model Notices: Condition I: Use for retrospective procedure denials. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We determined that your admission was medically necessary and appropriate. However, the (name of procedure) that was performed on (date) is denied for Medicare payment. Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under condition I, III, IV, V, IX, or X. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 29 - Day Outlier Denial Model Notice - (Rev. 4, 07-18-03) Use for retrospective day outlier denials (PPS hospitals) and retrospective partial admission denials (non-PPS hospitals) based on inappropriate setting, medically unnecessary, or custodial care. This applies to those cases where days are carved-out from the outlier period of a PPS admission or from a non-PPS admission. In those cases where the denial is for an uninterrupted period (i.e., beginning at a specified date through discharge), use the appropriate continued-stay denial model notice (See Exhibit 7-27).  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Day Outlier Denial Model Notice: YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We determined that your admission was medically necessary and appropriate. However, the inpatient hospital services you received (specify denied date(s)) for a total of (number) day(s) are denied for Medicare payment. Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under Condition I, II, IV, V, IX, or X. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-30 - Cost Outlier Denial Model Notices - (Rev. 4, 07-18-03) Identify the denial condition, and use the appropriate model notice. Condition I: Use for retrospective denials of services or items based on inappropriate setting or medically unnecessary.  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Condition II: Use for retrospective denials of services or items based on duplicative billing, or for services not actually furnished or not ordered by the physician.  Opportunity for discussion does not apply.  Limitation of liability (§1879 of the Act) does not apply.  Reconsideration does not apply.  Do not notify the beneficiary.  For inpatient hospital services furnished on or after January 1, 1989, through December 31, 1989, delete reference to the beneficiary's responsibility for the coinsurance payment. Cost Outlier Denial Model Notices: Condition I: Use for retrospective denials of services or items based on inappropriate setting or medically unnecessary. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed your admission of (date) to (name of provider) for (specify the procedure/treatment or condition/services). We determined that your admission was medically necessary and appropriate. However, certain inpatient hospital service(s) and item(s) you received are denied for Medicare payment. Prior to reaching this decision, we gave your physician and the hospital an opportunity to discuss your case. The specific service/item(s) are as follows: Specific Service/Item Date of Service/Item Charges After a review of your medical record and any additional information provided, we determined that (give a complete, fact-specific discussion of why admitted, care received, reason Medicare is denying, etc.). Select appropriate limitation of liability paragraph in Exhibit 7-20 under Condition I, II (cost outlier without a physician component denials based on inappropriate setting or medically unnecessary), III (cost outlier with a physician component denials based on medically unnecessary), IV, or V. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition II: Use for retrospective denial of services or items based on duplicative billing, or for services not actually furnished or not ordered by the physician. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physicians have reviewed the above admission of (date) for (specify the procedure/treatment or condition/services). We have determined that the admission was medically necessary and appropriate. However, certain inpatient hospital service/item(s) are denied for Medicare payment. The specific services/items are as follows: Specific Service/Item Date of Service/Item Charges After a review of the medical record, we determined that (relate discussion to the specific reason for denial).  Duplicative billing occurred;  Services/items not actually furnished; or  Services/items were not ordered by the physician. Medicare will not pay the hospital for the denied services. The beneficiary or his/her representative is only responsible for payment of any applicable amounts for deductible and coinsurance related to covered services and any amounts for convenience services and items normally not covered by Medicare. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-31 - DRG Changes as a Result of DRG Validation Model Notice - (Rev. 4, 07-18-03) Use when retrospective review results in changes that affect the DRG assignment.  Opportunity for discussion applies.  Re-review applies (Reconsideration does not apply).  Do not notify the beneficiary. DRG Changes as a Result of DRG Validation Model Notice: YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. We are also required to perform Diagnostic Related Group (DRG) validation on all cases selected for review to ensure that the diagnostic and procedural codes reported by the provider and resulting in the DRG assignment by the Fiscal Intermediary (FI) match both the documentation in the medical record and the physician's attestation. We have reviewed the above admission of (date) for (specify the procedure/treatment or condition/services). An opportunity to discuss this case was given to the provider and the physician. We have determined that the admission was medically necessary and appropriate. However, based on a review of the medical record and any other information available, we have changed the following code(s):  Hospital submitted code(s) and narrative description  QIO coding change(s) and narrative description This has resulted in a change in the DRG assignment from (__________) to (__________). After a review of the medical record and any additional information provided, we determined that (relate discussion to the specific reason for the change(s)). If the provider or physician disagrees with our determination, either party may request a re-review. You must submit your request for a re-review in writing within 60 days from receipt of this notice directly to us at: QIO Name Address Telephone Number This information is being reported to the FI for a payment adjustment. Sincerely, Medical Director (or designated physician) Chief Executive Officer, RRA, or ART, as appropriate ccs: Physician FI Carrier Exhibit 7-32 - Outpatient/Ambulatory Surgery Denial Model Notices - (Rev. 4, 07-18-03) Identify the denial condition, and use the appropriate model notice. This applies to hospital outpatient settings and ambulatory surgical centers. Condition I: Use for pre-procedure denials.  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) does not apply.  Reconsideration applies (See Exhibit 7-21). Condition II: Use for post-procedure denials (either prepayment or post-payment). Use this model letter if the procedure performed is non-covered as not medically necessary.  Opportunity for discussion applies.  Limitation of liability (§1879 of the Act) applies (See Exhibit 7-20).  Reconsideration applies (See Exhibit 7-21). Outpatient/Ambulatory Surgery Denial Model Notices: Condition I: Use for pre-procedure denials. YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review outpatient/ambulatory surgical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physician reviewers have denied Medicare payment for your proposed surgery of (date) (specify, if known: at (name of provider)) for (specify the surgical procedure). Prior to reaching this decision, we gave your physician (if known, add: and the provider) an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (Relate discussion to the specific reason(s) for denial). Medicare will not pay for your proposed surgery if you and your physician decide you should proceed with the surgery. Therefore, you will be responsible for payment of all costs for the services you receive. We are also advising your physician (if known, add: and the provider) of this denial. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate care you may require in the future. Use reconsideration paragraph in Exhibit 7-21 under Condition I. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Condition II: Use for post-procedure denials (either prepayment or post-payment). YOUR LETTERHEAD Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review outpatient/ambulatory surgical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our physician reviewers have denied Medicare payment for your surgery of (date) at (facility name) for (specify the surgical procedure). Prior to reaching this decision, we gave your physician and the provider an opportunity to discuss your case. After a review of your medical record and any additional information provided, we determined that (Relate discussion to the specific reason(s) for denial). Select appropriate limitation of liability paragraph in Exhibit 7-20 under condition XI, XII, or XIII. Use reconsideration paragraph in Exhibit 7-21 under Condition III. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director (or designated physician) ccs: Hospital Physician FI Carrier Exhibit 7-33 - Continued-stay Denial Completed Notice – (Rev. 4, 07-18-03) YOUR LETTERHEAD: Peer System, Inc. 1000 Pine Drive Baltimore, Maryland 12345 410-555-5555 Date of Notice: August 12, 1990 Name of Patient: John Doe Address: 200 Cherry Drive City, State, and Zip Code: Somewhere, MD 00000 Health Insurance Claim (HIC) Number: 000-00-0000 A Provider Name: Nowhere Hospital Provider Number: 21-0000 Medical Record Number (if known): 2222 Admission Date: August 1, 1990 Physician Name: John Smith, M.D. Dear Mr. Doe: The Peer System, Inc., is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of Maryland. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. On August 11, you requested that we review your case because you received, with your physician's concurrence, a notice of non-coverage from Nowhere Hospital on August 10. Our physicians have reviewed your admission of August 1 to Nowhere Hospital for medical and surgical treatment related to gallstones. We have determined that your admission was medically necessary and appropriate. We agree, however, with your physician and the hospital that for the reasons specified below, as of August 13, the services you are currently receiving are not covered by Medicare because they are no longer medically necessary in the hospital inpatient setting and they can be given safely and effectively outside of a hospital. Therefore, any inpatient hospital services you receive beginning after noon, August 13, will not be paid by Medicare. Prior to reaching this decision, we considered the information provided through telephone discussions with you on August 12, and any comments received from your physician and the hospital. After a review of your medical record and the information provided, we determined that you no longer require acute care in a hospital setting. The medical records show that you were admitted on August 1 with complaints of nausea and vomiting of several days duration. After receiving intravenous fluid replacement, a decision was made to remove your gall bladder, which was accomplished on August 3. By August 7, you were no longer taking injections for pain control and were tolerating a regular diet. By August 8, you were up and about in your room and the hall. On August 9, your physician removed your stitches and noted that your incision was well healed with no drainage. By August 10, you were receiving only your oral diuretic, the dosage being the same as when you were admitted. Thus, by the time the hospital gave you the notice of non-coverage, you required only the administration of an oral medication. We notified you by telephone on August 12, of our determination that the services you are receiving are not covered by Medicare and that if you decided to remain in the hospital after 12 noon on August 13, you would be responsible for payment of all costs of hospital services you receive after that time except for those covered services which can be paid for by Medicare Part B. If you decide to leave the hospital prior to 12 Noon on August 13, you will be responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and the hospital of this denial. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment for denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. If you disagree with our determination and you decide to remain in the hospital, you, your physician, or hospital may appeal this denial decision, while you are still in the hospital, by requesting an expedited reconsideration through the hospital by telephoning or by writing us at: Peer System, Inc. 1000 Pine Drive Baltimore, Maryland 12345 410-555-5555 We will complete our expedited reconsideration and send a written notice to you within three working days. However, if you don't remain in the hospital after 12 Noon on August 13 or if you remain in the hospital and do not request an expedited reconsideration, you, your physician, or hospital are still entitled to a reconsideration. You must submit your request in writing within 60 days from the receipt of this notice to us at the above address. You may also make your request to any Social Security Office or Railroad Retirement Office (if you are a Railroad Retirement beneficiary). Your request will be forwarded to us. As a result of our review, we may reaffirm or reverse our prior denial determination. If we reaffirm the denial determination, you will continue to be responsible for payment of services furnished as specified above. If we reverse the denial determination, you will be refunded any amount collected by the hospital except for payment of deductible, coinsurance, or any convenience services or items normally not covered by Medicare. If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely, Medical Director ccs: Hospital Physician FI Carrier Exhibit 7-34 - Circumvention of Prospective Payment System (PPS) Denial Model Notice - (Rev. 4, 07-18-03) Use for retrospective Part A denials involving PPS and PPS-excluded admissions and readmissions within the same PPS hospital based on your determination that the services should have been furnished during the first admission or that the discharge and subsequent admission were inappropriate. This also applies to discharges from PPS and PPS-excluded units and subsequent admissions to hospital-based Skilled Nursing Facility (SNF) and SNF swing beds.  Opportunity for discussion applies.  Limitation on liability (§1879 of the Act) does not apply.  Reconsideration applies (See Exhibit 7-50).  Do not notify the beneficiary or physician. Circumvention of PPS Denial Model Notice: (Do not notify the beneficiary or physician). LETTERHEAD OF THE QIO Date of Notice Name of Provider Address of Provider City, State, and Zip Code Patient Name Health Insurance Claim (HIC) Number Medical Record Number (if known) First Admission Date Readmission/Transfer Date PPS Provider Number PPS-excluded Provider Number (if known) Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Select paragraph A, B, or C below: A: Services Should Have Been Furnished During the First Admission Our physicians have reviewed the acute care admission of (date) for (specify the procedure/treatment or condition/services) and subsequent acute care readmission of (date) for (specify the procedure/treatment or condition/services). We have determined that the services furnished were medically necessary and appropriate. However, the services should have been furnished during the first admission. This action is considered to be a circumvention of the prospective payment system because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital admitted the patient on (date) and again on (date), the hospital received two Medicare payments instead of one. Therefore, we are denying Medicare payment for the readmission of (date of 2nd admission). B: Inappropriate Transfer From a PPS Unit to a PPS-Excluded Unit (This also applies to similar transfers from a PPS unit to a hospital-based SNF or SNF swing bed). Our physicians have reviewed the acute care admission of (date) for (specify the procedure/treatment or condition/services) and subsequent admission of (date) to the (select: psychiatric unit, rehabilitation unit, hospital-based Skilled Nursing Facility (SNF), or SNF swing bed) for (specify the procedure/treatment or condition/services). We have determined that the patient was admitted to the acute care hospital even though the medical record shows that the patient only required care in the (select: psychiatric unit, rehabilitation unit, hospital-based SNF, or SNF swing-bed) and a bed was available at the time of the acute care admission. This action is considered to be a circumvention of the prospective payment system because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital discharged the patient on (date) and subsequently admitted the patient on (date), the hospital received two Medicare payments instead of one. Therefore, we are denying Medicare payment for the admission of (date of 2nd admission). C: Inappropriate Transfer From a PPS-Excluded Unit to a PPS Unit (This also applies to similar transfers from a PPS-excluded unit to a hospital-based SNF or SNF swing bed). Our physicians have reviewed the admission of (date) to the (select: psychiatric or rehabilitation) unit for (specify the procedure/treatment or condition/services) and subsequent admission of (date) to the (select: acute care hospital, hospital-based SNF, SNF swing bed) for (specify the procedure/treatment or condition/services). We have determined that the admission to the (select: psychiatric or rehabilitation) unit was medically necessary and appropriate and that the patient continued to require (select: psychiatric or rehabilitation) care/services when transferred to the (select: acute care hospital, hospital-based SNF, or SNF swing-bed). This action is considered to be a circumvention of the prospective payment system because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital discharged the patient on (date) and subsequently admitted the patient on (date), the hospital received two Medicare payments instead of one. Therefore, we are denying Medicare payment for the admission of (date of 2nd admission). This denial determination is made under §1886(f)(2) of the Social Security Act. This section authorizes a denial of payment under Part A when the Secretary determines, based on information provided by a QIO that a hospital has taken an action, in order to circumvent PPS, which results in unnecessary admissions, multiple admissions of the same individual, or other inappropriate practices. Prior to reaching this decision, we gave you an opportunity to discuss this case. After a review of the medical record and any additional information provided, we determined that (Give a complete, fact-specific discussion related to the reason for denial under paragraph A, B, or C). The limitation on liability provision of §1879 of the Act does not apply to Part A denials issued under §1886(f)(2) of the Act. Therefore, the hospital is liable for the charges of the denied services. The beneficiary or his/her representative is only responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. If the beneficiary or his/her representative has paid the hospital for any of the denied services other than those amounts already mentioned, the hospital is to refund such payment. If you disagree with our determination, you may appeal this denial decision by requesting a reconsideration. You must submit your request in writing within 60 days from receipt of this notice directly to us at: QIO Name Address Telephone Number Sincerely, Medical Director (or designated physician) ccs: FI Carrier Exhibit 7-40 - Reconsideration Notices -- Hearings Model Paragraphs - (Rev. 4, 07-18-03) Condition I: Use in your reconsideration notice when you affirm or partially reverse an initial denial determination that was based on medical necessity or appropriateness of setting, or when you affirm your liability determination that the beneficiary knew that the denied services would not be covered by Medicare. If you disagree with our reconsideration determination, you may request a formal hearing before an Administrative Law Judge (ALJ) of the Social Security Administration's (SSA's) Office of Hearings and Appeals (OHA) under the following conditions:  If Medicare has denied payment of $200 or more for services determined to be either not medically necessary or not provided at an appropriate level of care; or  If you do not appeal the denial of Medicare payment on the medical issues listed above and have been found liable for payment of at least $100 of the denied services, and you disagree with our liability determination that you knew or should have known that the denied services were not covered. If you do not request an ALJ hearing regarding the liability determination, a dissatisfied provider or practitioner may request an ALJ hearing of that liability determination if they are liable for services of $100 or more. If you wish to have an ALJ hearing, you must submit a written request within 60 calendar days of receipt of this notice. Your written request should include: your name, Medicare health insurance claim number, where and when services were received, the reason for your dissatisfaction with our determination, any additional evidence you might wish to submit, and a copy of this notice. You may send your written request to:  Any social security office;  An office of SSA's OHA;  An office of the Railroad Retirement Board, if you are eligible; or  To us at the following address: QIO Name Address (including zip code) Telephone Number (A provider or practitioner may only send a written request to us or OHA.) If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making our initial denial and reconsideration determinations. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. If you request a hearing, OHA will notify you of the date and place of the hearing. Hearings are held close to the address given on requests; therefore, if you request a hearing, please include the name of the county in which you reside along with your complete address and zip code. If you wish the hearing to be held somewhere other than close to your residence, please note that on the hearing request. Condition II: Attach this paragraph to the provider/physician copy of the beneficiary reconsideration notice, as appropriate. According to §1879(d) of the Social Security Act, if the amount in controversy is at least $100.00, a beneficiary who is dissatisfied with the limitation on liability reconsideration determination may obtain an administrative hearing conducted by an ALJ of the OHA of SSA. If the beneficiary chooses not to exercise his or her appeal rights regarding the limitation on liability determination, you (a dissatisfied provider or a dissatisfied practitioner) are entitled to an administrative hearing conducted by an ALJ only addressing the issue of whether you knew or should have known that services would not be covered. If you wish to have an ALJ hearing regarding the limitation on liability reconsideration determination, you must submit a written request within 60 calendar days of receipt of this notice (unless time is extended for good cause). Your written request should include: beneficiary's name, Medicare health insurance claim number, where and when services were provided, the reason for your dissatisfaction with our determination, any additional evidence you might wish to submit, and a copy of this notice. You may send your written request to:  An office of SSA's OHA; or  To us at the following address: QIO Name Address (including zip code) Telephone Number If you request a hearing, OHA will notify you of the date and place of the hearing. Hearings are held close to the address given on requests; therefore, if you request a hearing, please include the name of the county in which you are located along with your complete address and zip code. If you wish the hearing to be held somewhere other than close to your place of business, please note that on the hearing request. Exhibit 7-41 - Reconsideration Model Notice -- Preadmission Denial - (Rev. 4, 07-18-03) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name (if known) Provider Number (if known) Medical Record Number (if known) Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for (insert either "an expedited reconsideration" or "a reconsideration"), we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer denied Medicare payment for your proposed admission of (date), to (name of provider) for (specify the procedure/treatment or condition/services) because (use the medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that if you and your physician decided that you should be admitted to the hospital, you would be responsible for payment of all costs for the denied services you received except for those covered services which could be paid for by Medicare Part B. Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the hospital. The physician reviewer (insert either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for your proposed admission if you and your physician decide that you should be admitted to the hospital. NOTE: If you reverse your initial denial determination, insert: "If admitted, you will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." NOTE: If you uphold your initial denial determination, insert: "If admitted, you will be responsible for payment of all costs of the denied services you receive except for those covered services which can be paid for by Medicare Part B." We are also advising your physician and the hospital of this reconsideration determination, which affirms our original denial determination. You should discuss with your physician other arrangements for any further health care you may now require. NOTE: Include the above paragraph only if you uphold your initial denial determination. Upon receipt of this notice, you will continue to be responsible for payment of denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. NOTE: If you reverse your initial denial determination, insert: "If admitted, you will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." NOTE: If you uphold your initial denial determination, insert: "If admitted, you will be responsible for payment of all costs of the denied services you receive except for those covered services which can be paid for by Medicare Part B." Use Model Hearings Paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/ carrier (if original denial/liability determination changes) Exhibit 7-42 - Reconsideration Model Notice -- Admission Denial – (Rev. 4, 07-18-03) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for a reconsideration, we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer denied Medicare payment for your admission of (date), to (name of provider) for (specify the procedure/treatment or condition/services) because (use medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that (use the limitation on liability determination and rationale for the beneficiary, provider, and/or practitioner contained in the initial denial notice). Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the hospital. The physician reviewer (select either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for your admission. NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1. Include future liability language). NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-43 - Reconsideration Model Notice -- Continued-stay Denial - (Rev. 4, 07-18-03) (Expedited Reconsideration Within Three Working Days) (Physician Agrees with HINN) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for an expedited reconsideration, we conducted a complete review of your medical record to determine whether our original denial determination was correct. You received, with your physician's concurrence, a notice of non-coverage from (name of provider) on (date), and requested that we review your hospital stay. A QIO physician reviewer determined that your admission of (date), to (name of provider) for (specify the procedure/treatment or condition/services) was medically necessary and appropriate. However, the physician reviewer agreed with your physician and the hospital that beginning (date of first non-covered acute care day), you no longer required acute care in a hospital setting because (use medical information and rationale contained in the initial denial notice). On (date of notification), we notified you that we agreed with (name of provider)'s notice of non-coverage, and issued a denial determination. You were advised that if you decided to remain in the hospital, beginning (insert date given in denial notice), you would be responsible for payment of all costs of denied services you received, except for those covered services which could be paid for by Medicare Part B. Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or hospital. The physician reviewer (select either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will pay the hospital for the inpatient services you are receiving" or "will not pay the hospital for the inpatient services provided (except for those covered services which can be paid for by Medicare Part B) beginning (date)"). NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." NOTE: If you uphold your initial denial determination, insert: "Also, the hospital may send you a bill for services provided to you beginning (date)." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1). NOTE: Include the above paragraph only if you uphold your initial denial determination. We are also advising your physician and the hospital of this reconsideration determination, which affirms our original denial determination. You should discuss with your physician other arrangements for any further health care you may now require. NOTE: Include the above paragraph only if you uphold your initial denial determination. Upon receipt of this notice, you will continue to be responsible for payment of denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-44 - Reconsideration Model Notice -- Procedure Denial – (Rev. 4, 07-18-03) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for reconsideration, we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer determined that your admission of (date), to (name of provider) for (specify the treatment, condition, or services) was medically necessary and appropriate. However, the physician reviewer denied Medicare payment for the (name of procedure) that was performed on (date) because (use the medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that (use the limitation on liability determination and rationale for the beneficiary, provider, and/or practitioner contained in the initial denial notice). Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the hospital. The physician reviewer (insert either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Cite the appropriate statutory and regulatory citations. Give a complete fact-specific discussion of why the patient was admitted, the care received, and the reason Medicare is denying or paying for the procedure). Therefore, we have determined that Medicare (select either "will" or "will not") pay for the (name of procedure) provided on (date), for (amount of dollars). Medicare will pay for the medically necessary care and services you received on admission to (name of provider) from (date of admission) to (date of discharge). NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items not normally covered by Medicare." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1. Include future liability language). NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-45 - Reconsideration Model Notice -- Day Outlier Denial - (Rev. 4, 07-18-03) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for reconsideration, we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer determined that your admission of (date), to (name of provider) for (specify the procedure/treatment or condition/services) was medically necessary and appropriate. However, the physician reviewer denied Medicare payment for the inpatient hospital services you received (specify denied date(s)) for a total of (number) day(s) because (use medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that (use the limitation on liability determination and rationale for the beneficiary, provider, and/or practitioner contained in the initial denial notice). Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the hospital. The physician reviewer (insert either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for the inpatient hospital services you received (specify denied date(s)) for a total of (number) day(s). NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1. Include future liability language). NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-46 - Reconsideration Model Notice -- Cost Outlier Denial - (Rev. 4, 07-18-03) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for reconsideration, we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer determined that your admission of (date), to (name of provider) for (specify the procedure/treatment or condition/services) was medically necessary and appropriate. However, the physician reviewer denied Medicare payment for the inpatient hospital service(s) and/or item(s) that you received as follows: Specific Service/Item Date Service/Item Charges Payment was denied because (use medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that (use the limitation on liability determination and rationale for the beneficiary, provider, and/or practitioner contained in the initial denial notice). Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or hospital. The physician reviewer (insert either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for the inpatient hospital service(s) and/or item(s) previously specified. NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1. Include future liability language). NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-47 - Re-review Model Notice -- DRG Changes as a Result of DRG Validation - (Rev. 4, 07-18-03) (To provider - do not notify the beneficiary) LETTERHEAD OF THE QIO Date of Notice Name of Patient Address City, State, and Zip Code Health Insurance Claim (HIC) Number Provider Name Provider Number Medical Record Number (if known) Admission Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. We also are required to perform Diagnostic Related Group (DRG) validation on all cases selected for review to ensure that the diagnostic and procedural codes reported by the provider and resulting in the DRG assignment by the Fiscal Intermediary (FI) matches both the documentation in the medical record and the physician's attestation. As a result of (insert either the name of the provider or physician) (date) request for a re- review, we have conducted a complete review of the medical record to determine whether our original DRG assignment determination was correct. A reviewer determined that the admission of (date), for (specify the procedure/treatment or condition/services) was medically necessary and appropriate. However, the reviewer changed the following code(s): Hospital Submitted Code(s) and Narrative Description QIO Coding Change(s) This resulted in a change in the DRG assignment from (_________) to (___________). The codes were changed because (use the reason for change contained in the DRG Validation notice). Prior to our re-review of the DRG assignment, we gave the physician, (name), and you an opportunity to provide additional information, if you wished. Based on a thorough re-examination of all the information contained in the medical record and consideration of any additional information provided by the physician and by you, the reviewer determined that the change in the DRG assignment (insert either "was" or "was not") correct because (include a brief statement of the facts of the case and the rationale used in upholding or reversing the initial DRG change). Therefore, the final results of the DRG re-review are as follows: QIO Determined Codes and Narrative Description: Final Determination: DRG ______________ The Social Security Act does not provide for further appeal of this determination. NOTE: Include the above paragraph only if you uphold your initial DRG change determination. If you have any further questions, please contact ______________. Sincerely, Medical Director (or designated physician, Chief Executive Officer, RRA, or ART, as appropriate) ccs: Physician FI/carrier (if final DRG determination changes) Exhibit 7-48 - Reconsideration Model Notice -- Outpatient/Ambulatory Surgery Denial - (Rev. 4, 07-18-03) Condition I: Use for pre-procedure denials. LETTERHEAD OF THE QIO Date of Notice Name of Patient Address of Patient City, State, and Zip Code Health Insurance Claim (HIC) Number Facility Name (if known) Facility Provider Number (if known) Medical Record Number (if known) Proposed Surgery Date Physician Name Dear: The (your name) is the Quality Improvement Organization authorized by the Medicare program to review outpatient/ambulatory surgical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for (insert either "an expedited reconsideration" or "a reconsideration"), we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer denied Medicare payment for your proposed surgery of (date), at (name of provider) for (specify the surgical procedure) because (use the medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that if you and your physician decided that you should proceed with the surgery, you would be responsible for payment of all costs for the denied services you receive except for those covered services which could be paid for by Medicare Part B. Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the provider. The physician reviewer (insert either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for your proposed surgery if you and your physician decide to proceed. NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." NOTE: If you uphold your initial denial determination, insert: "You will be responsible for payment of all costs of the denied services you receive." We also are advising your physician and provider of this reconsideration determination, which affirms our original denial determination. You should discuss with your physician other arrangements for any further health care you may now require. NOTE: Include the above paragraph only if you uphold your initial denial determination. Upon receipt of this notice, you will continue to be responsible for payment of denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate care you may require in the future. NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings Paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Condition II: Use for post-procedure denials (either prepayment or post-payment). LETTERHEAD OF THE QIO Date of Notice Name of Patient Address of Patient City, State, and Zip Code Health Insurance Claim (HIC) Number Facility Name Facility Provider Number Medical Record Number (if known) Surgery Date Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review outpatient/ambulatory surgical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of (insert either "your" or the name of the physician or provider) (date), request for a reconsideration, we have conducted a complete review of your medical record to determine whether our original denial determination was correct. A QIO physician reviewer denied Medicare payment for your surgery of (date), at (name of provider) for (specify the surgical procedure) because (use the medical information and rationale contained in the initial denial notice). When we notified you on (date of denial notice) of this denial determination, you were advised that (use the limitation on liability determination and rationale for the beneficiary, provider, and/or practitioner contained in the initial denial notice). Prior to our reconsideration of this denial determination, we gave your physician, (name), and (name of provider) an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or the provider. The physician reviewer (select either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations). Therefore, we have determined that Medicare (select either "will" or "will not") pay for your surgery. NOTE: If you reverse your initial denial determination, insert: "You will only be responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare." The physician reviewer also reconsidered the original liability determination that (insert the liable parties, i.e., "you" and/or the name of the provider and/or physician) knew that the denied services were not covered by Medicare. The physician reviewer determined that (Provide the facts and rationale for upholding/reversing the original liability determination for all parties. Include the appropriate statutory and regulatory citations. If your liability determination remains unchanged, tailor the liability language to the limitation on liability information contained in the initial denial notice. If your liability determination changes, tailor the liability language to the appropriate limitation on liability condition found in Exhibit 7-1. Include future liability language). NOTE: Include the above paragraph only if you uphold your initial denial determination. Use Model Hearings paragraph Exhibit 7-40, Condition I (and Condition II, if appropriate). NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: Provider Physician FI/carrier (if original denial/liability determination changes) Exhibit 7-49 - Reconsideration Completed Notice -- Continued-stay Denial - (Rev. 4, 07-18-03) (Expedited Reconsideration Within Three Working Days) (Physician Agrees with HINN) YOUR LETTERHEAD: Peer System, Inc. 1000 Pine Drive Baltimore, Maryland 12345 410-555-5555 Date of Notice: August 12, 1990 Name of Patient: John Doe Address: 200 Cherry Drive City, State, and Zip Code: Somewhere, MD 00000 Health Insurance Claim (HIC) Number: 000-00-0000 A Provider Name: Nowhere Hospital Provider Number: 21-0000 Medical Record Number (if known): 2222 Admission Date: August 1, 1990 Physician Name: John Smith, M.D. Dear Mr. Doe: The Peer System, Inc., is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of Maryland. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of your August 13, request for an expedited reconsideration, we conducted a complete review of your medical record to determine whether our original denial determination was correct. You received, with your physician's concurrence, a notice of non-coverage from Nowhere Hospital on August 10, 1990, and requested that we review your hospital stay. A QIO physician reviewer determined that your admission of August 1, 1990, to Nowhere Hospital for medical and surgical treatment of gallstones was medically necessary and appropriate. However, the physician reviewer agreed with your physician and the hospital that beginning August 10, you no longer required acute care in a hospital setting since you were receiving only a medication by mouth. That service, which can be safely provided outside of a hospital, does not constitute a hospital level of care and, therefore, is not covered by Medicare. On August 12, we notified you that we agreed with Nowhere Hospital's notice of non- coverage and issued a denial determination. You were advised that if you decided to remain in the hospital, beginning 12 noon on August 13, you would be responsible for payment of all costs of the denied services you received, except for those covered services which could be paid for by Medicare Part B. Prior to our reconsideration of this denial determination, we gave your physician, Dr. Smith, and Nowhere Hospital an opportunity to provide additional information, if they wished. The reconsideration was performed by a board-certified physician reviewer who specializes in abdominal surgery. The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in your medical record and considered any additional information provided by your physician and/or hospital. The physician reviewer upheld the original denial determination because services you received beginning August 10 could be given safely and effectively outside of a hospital. The medical records indicate that by that time you were up and about with no assistance, tolerating regular food, required no medication for pain control, and were taking only an oral diuretic in a maintenance dosage. Also, your stitches had been removed, and your incision was well healed and dry. Our authority for denying payment is specified in the Code of Federal Regulations, 42 CFR 473.14(a)(3). Therefore, we have determined that Medicare will not pay the hospital for the inpatient services provided (except for those covered services which can be paid for by Medicare Part B) beginning August 10. Also, the hospital may send you a bill for services provided to you beginning August 10. The physician reviewer also reconsidered the original liability determination that you are responsible for payment of services you received in the hospital after 12 Noon on August 13, because you knew that the services were not covered by Medicare. The physician reviewer determined that you received adequate notice when you received the August 10 notice of non-coverage from the hospital and our telephone and written notice of August 12. Thus, your liability for the cost of the non-covered services received after 12 Noon on August 13 cannot be waived. Your liability for payment is specified in §1879 of the Social Security Act, and in the Code of Federal Regulations, 42 CFR Part 405. This reconsideration determination notifies you that the services denied are not covered under Medicare. As you were notified in our August 12 denial notice, beginning 12 Noon on August 13, you became responsible for payment of all costs of services you receive in the hospital except for those covered services which can be paid for by Medicare Part B. For hospital services received prior to 12 Noon on August 13, you are responsible only for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. We are also advising your physician and the hospital of this reconsideration determination, which affirms our original denial determination. You should discuss with your physician other arrangements for any further health care you may now require. Upon receipt of this notice, you will continue to be responsible for payment of denied services occurring in the future which involve the same or reasonably comparable conditions. However, Medicare will pay for all medically necessary and appropriate hospital care you may require in the future. If you disagree with our reconsideration determination, you may request a formal hearing before an Administrative Law Judge (ALJ) of the Social Security Administration's (SSA's) Office of Hearings and Appeals (OHA) under the following conditions:  If Medicare has denied payment of $200 or more for services determined to be either not medically necessary or not provided at an appropriate level of care; or  If you do not appeal the denial of Medicare payment on the medical issues listed above and have been found liable for payment of at least $100 of the denied services, and you disagree with our liability determination that you knew or should have known that the denied services were not covered. If you do not request an ALJ hearing regarding the liability determination, a dissatisfied provider or practitioner may request an ALJ hearing of that liability determination if they are liable for services of $100 or more. If you wish to have an ALJ hearing, you must submit a written request within 60 calendar days of receipt of this notice. Your written request should include: your name, Medicare health insurance claim number, where and when services were received, the reason for your dissatisfaction with our determination, any additional evidence you might wish to submit, and a copy of this notice. You may send your written request to:  Any social security office;  An office of SSA's OHA;  An office of the Railroad Retirement Board, if you are eligible; or  To us at the following address: Peer System, Inc. 1000 Pine Drive Baltimore, Maryland 12345 410-555-5555 (A provider or practitioner may only send a written request to us or OHA.) If you want help with your appeal of this denial determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making our initial denial and reconsideration determinations. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. If you request a hearing, OHA will notify you of the date and place of the hearing. Hearings are held close to the address given on requests; therefore, if you request a hearing, please include the name of the county in which you reside along with your complete address and zip code. If you wish the hearing to be held somewhere other than close to your residence, please note that on the hearing request. Sincerely, Medical Director ccs: Nowhere Hospital John Smith, M.D. Exhibit 7-50 - Reconsideration Model Notice -- Circumvention of Prospective Payment System (PPS) - (Rev. 4, 07-18-03) (Do not notify the beneficiary or physician) LETTERHEAD OF THE QIO Date of Notice Name of Provider Address of Provider City, State, and Zip Code Patient Name Health Insurance Claim (HIC) Number Medical Record Number (if known) First Admission Date Readmission/Transfer Date PPS Provider Number PPS-excluded Provider Number (if applicable) Physician Name Dear: The (your name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review inpatient hospital services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. As a result of your (date) request for a reconsideration, we have conducted a complete review of the medical record to determine whether our original denial determination was correct. Select paragraph A, B, or C below: A: Services Should Have Been Furnished During the First Admission Our physicians previously reviewed the acute care admission of (date) for (specify the procedure/treatment or condition/services) and subsequent acute care readmission of (date) for (specify the procedure/treatment or condition/services). We determined that the services furnished were medically necessary and appropriate. However, the services should have been furnished during the first admission. This action was considered to be a circumvention of the PPS because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital admitted the patient on (date) and again on (date), the hospital received two Medicare payments instead of one. Therefore, we denied Medicare payment for the readmission of (date of 2nd admission). B: Inappropriate Transfer From a PPS Unit to a PPS-excluded Unit NOTE: This also applies to similar transfers from a PPS unit to a hospital-based SNF or SNF swing bed. Our physicians previously reviewed the acute care admission of (date) for (specify the procedure/treatment or condition/services) and subsequent admission of (date) to the (select: psychiatric unit, rehabilitation unit, hospital-based Skilled Nursing Facility (SNF), or SNF swing bed) for (specify the procedure/treatment or condition/services). We determined that the patient was admitted to the acute care hospital even though the medical record shows that the patient only required care in the (select: psychiatric unit, rehabilitation unit, hospital-based SNF, or SNF swing bed) and a bed was available at the time of the acute care admission. This action was considered to be a circumvention of the prospective payment system because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital discharged the patient on (date), the hospital received two Medicare payments instead of one. Therefore, we denied Medicare payment for the admission of (date of 2nd admission). C: Inappropriate Transfer From a PPS-excluded Unit to a PPS Unit NOTE: This also applies to similar transfers from a PPS-excluded unit to a hospital- based SNF or SNF swing bed. Our physicians previously reviewed the admission of (date) to the (select: psychiatric or rehabilitation) unit for (specify the procedure/treatment or condition/services) and subsequent admission of (date) to the (select: acute care hospital, hospital-based SNF, or SNF swing bed) for (specify the procedure/treatment or condition/services). We determined that the admission to the (select: psychiatric or rehabilitation) unit was medically necessary and appropriate and that the patient continued to require (select: psychiatric or rehabilitation) care/services when transferred to the (select: acute care hospital, hospital-based SNF, or SNF swing bed). This action was considered to be a circumvention of the PPS because each admission triggered payment for an entire episode of hospital care. Thus, when the hospital discharged the patient on (date) and subsequently admitted the patient on (date), the hospital received two Medicare payments instead of one. Therefore, we denied Medicare payment for the admission of (date of 2nd admission). This denial determination was based on (use the medical information and rationale contained in the initial denial notice). Prior to reaching our reconsideration determination, we gave you an opportunity to provide additional information, if you wished. The reconsideration was performed by a board-certified physician reviewer who specializes in (indicate the specialty of the physician). The physician reviewer, who was not involved in the original denial determination, performed a thorough re-examination of all the information contained in the medical record and considered any additional information provided by the hospital. The physician reviewer (select either "reversed" or "upheld") the original denial determination because (Provide the facts and rationale for upholding/reversing the original denial determination for all parties. Include the appropriate statutory and regulatory citations.) Therefore, we have determined that Medicare (select either "will" or "will not") pay for the (insert either "readmission" or "admission") of (date of second admission). This denial determination is made under §1886(f)(2) of the Social Security Act. This section authorizes a denial of payment under Part A when the Secretary determines, based on information provided by a QIO, that a hospital has taken an action, in order to circumvent PPS, which results in unnecessary admissions, multiple admissions of the same individual, or other inappropriate practices. NOTE: Include the above paragraph only if you uphold your initial denial determination. The limitation on liability provision of §1879 of the Act does not apply to Part A denials issued under §1886(f)(2) of the Act. Therefore, the hospital is liable for the charges of the denied services. The beneficiary or his/her representative is only responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare. If the beneficiary or his/her representative has paid the hospital for any of the denied services other than those amounts just mentioned, the hospital is to refund such payment. NOTE: Include the above paragraph only if you uphold your initial denial determination. If payment for services is denied due to alleged circumvention of the prospective payment system, you have a right to obtain a hearing conducted by an Administrative Law Judge of the Social Security Administration's (SSA's) Office of Hearings and Appeals (OHA) if the amount in controversy is $100 or more. To do so, submit a written request within 60 calendar days of receipt of this notice. Your written request should include: beneficiary's name, Medicare health insurance claim number, where and when services were provided, the reason for your dissatisfaction with our determination, any additional evidence you may wish to submit, and a copy of this notice. NOTE: Include the above paragraph only if you uphold your initial denial determination. The request for a hearing may be sent to:  An office of SSA's OHA; or  To us at the following address: QIO Name Address Telephone Number NOTE: Include the above paragraph only if you uphold your initial denial determination. If you request a hearing, OHA will notify you of the date and place of the hearing. Hearings are held close to the address given on requests; therefore, if you request a hearing, please include the name of the county in which you are located along with your complete address and zip code. If you wish the hearing to be held somewhere other than close to your place of business, please note that on the hearing request. NOTE: Include the above paragraph only if you uphold your initial denial determination. Sincerely, Medical Director (or designated physician) ccs: FI/carrier (if original denial determination changes) Exhibit 7-60 - Sample Acknowledgment Letter to Beneficiary/ Representative When Request Is Sent to the Hearing Office – (Rev. 4, 07-18-03) _________________________ _________________________ _________________________ _________________________ H.I. Claim Number: ____________________ Dear ________________: This is in reply to your request for a hearing before an Administrative Law Judge. We have forwarded the file to: Office of Hearings and Appeals (OHA) ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ OHA will notify you as to the time and place of the hearing. If you have any further questions regarding this matter, OHA will be glad to assist you. If you want help with your appeal of this reconsideration determination, you can have a friend, lawyer, or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify. You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making our initial denial and reconsideration determinations. Although the hospital is the official repository of medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed below: QIO Name Address (including zip code) Telephone Number There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information. Sincerely yours, cc: File Folder Exhibit 7-61 - How to Locate the Correct Hearing Office – (Rev. 4, 07-18-03) The Administrative Law Judge Hearing Offices (HO) serve particular Social Security District Offices (DO). Therefore, to locate the correct HO to which you must send the hearing folder, you need to know the DO that services the beneficiary. If the requestor is not the beneficiary, use the DO closest to the requestor's address to determine the HO to which the hearing folder is sent. Since the SSA DOs serve specific counties within the State, it is also necessary for you to determine in which county the beneficiary/requestor resides before you can locate the DO. For these reasons use the following directories:  U.S. Postal Service Directory of Post Offices;  DHHS/SSA Service Area Directory (SAD); and  OHA Field Office Directory. Using the U.S. Postal Service Directory of Post Offices -- You need this directory to locate the county in which the beneficiary/requestor resides. Once you determine the city, State, and zip code on the request for hearing, locate that city under the "State Listing" in the Postal Service Directory. The county in which that city is located is listed either next to, or below, the city's name. Using the DHHS/SSA SAD -- Once you have determined the county where the beneficiary/requestor resides, you need to know which SSA DO services that county. This directory is divided into several headings. Use columns marked County, Post Office, and Servicing Office. The counties are listed alphabetically under each State. Find the name of the county under the County heading. The name of the city appears under the Post Office heading. The name of the SSA DO is listed under the Servicing Office. The city may be broken down further into zip code areas. Therefore, it may be necessary for you to determine the correct zip code before you can determine the Servicing Office or SSA DO. At this point, call the DO and request the address of the specific local HO. Also, request the DO to provide you with addresses of all the HOs in its area for future use. The SSA SAD can be retrieved electronically by using the SSA National Bulletin Board Service (SSANBBS). SSANBBS contains both directory and monthly update SAD files. Directory SAD files contain the complete directory updated through a specified month. A directory file can be identified by a "D" in the file name. For example, SAD_DSEP.EXE would be the complete directory including updates through September while SAD_DOCT.EXE would be the complete directory including updates through October. Usually, SSANBBS contains the current and prior month directory files. Directory files are very large and very time consuming to download. Monthly update SAD files contain only the changes for that month. They do not contain the entire directory. A monthly update file can be identified by a "U" in the file name. For example, SAD_USEP.EXE would be the monthly update for September while SAD_UOCT.EXE would be the monthly update for October. Usually, SSANBBS contains the current and prior month update files. Update files are much smaller and much less time consuming to download. Bear in mind that the monthly update files contain only the changes for that month. Therefore, download them consistently or your directory will not be up-to-date. If you choose not to download the monthly updates, you may want to periodically download the complete directory. To access SSANBBS, use any PC communication package such as PROCOMM or PCTALK that provides for the XMODEM protocol. Then enter the following information into the dial area of your communication software: SSANBBS Phone Number: 1-410-965-5780 Baud Rate: 1200/2400 Data Bits: 8 Parity: NONE Stop Bits: 1 Duplex Mode: Full Once you have accessed SSANBBS, download the complete directory or monthly update files by entering the following information:  At the Logo screen, hit enter and key in your name and password.  At the Main Menu screen, select D (Download Facility).  At the File Directories Menu screen, select 40 (Electronic Publications).  At the Electronic Publications Menu screen, select the desired SAD file.  At the message "Starting to Download Begin Receiving Using XMODEM Protocol," depress the page down (PROCOMM) key or the key that is appropriate to begin downloading for your software.  Select XMODEM Protocol and download as the file name on the SSANBBS or change it to suit your needs. If you experience any problems accessing SSANBBS or downloading SAD files, call the Help Desk on 1-410-965-6171. The following example shows you how the above directories are used in locating the HO to which the hearing folder is sent for a beneficiary residing in Tampa, Florida 33630. Using the Postal Service Directory, the county in which Tampa is located is Hillsborough. Using the SSA Service Area Directory (State Listing), locate Hillsborough under the County heading. Under the Post Office heading, note that the city of Tampa is broken out by zip codes. Zip code 33630 is serviced by the Wellswood DO. If the Tampa zip code did not match any of those listed, use "Tampa Other Zips" and Tampa DO. Exhibit 7-71 - Potential Quality Concern Model Notice – (Rev. 4, 07-18-03) YOUR LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Patient Name Health Insurance Claim (HIC) Number Provider Name Provider Number Date of Admission/Service Medical Record Number (if known) Dear: The (QIO name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review medical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our primary purpose is to identify areas where care can be improved and to feed back information to physicians and providers. This peer review is intended to be a collegial interaction with the goal of improving patient care. We appreciate the time and effort involved in your cooperation with our review activities. A QIO physician reviewer has initially reviewed the care provided to (name of patient) at (name of provider) for (specify the procedure, treatment, condition, and/or services). Based on a careful review of the information contained in the medical record, the physician reviewer has raised some concerns regarding the care provided. (Summarize the case findings and concerns from the preliminary decision portion of the PRAF.) This is a potential concern only. We recognize that the medical record may not give a complete clinical picture. Therefore, we are providing you an opportunity to discuss the concerns we have raised prior to rendering our final determination. Your response can be in writing or by telephone. We must receive your response within 20 days from the date of this notice in order for information provided by you to be considered in our final determination. Please direct your response to: Name of QIO Contact Person Address Telephone Number If you have any questions concerning this notice or would like to make arrangements to discuss this case with a QIO physician reviewer, you may also contact (name of QIO contact person) within 20 days. We are also notifying (name (See NOTEs below)) of our concerns and offering an opportunity to discuss the concerns we have raised. While the physician and the representative for the provider may respond separately to the opportunity for discussion, we strongly encourage coordination of the responses. NOTE: If the notice is addressed to the provider, insert the name of the physician(s) also notified. NOTE: If the notice is addressed to the physician, insert the name of the provider. Do not specify other physicians you may be notifying. If we do not receive your response by (date), a QIO physician reviewer will make a final determination based on the information contained in the medical record alone. The information in this notice is confidential and may be re-disclosed only in accordance with Federal regulations found in 42 CFR 476.107 and 108. Sincerely, Medical Director (or designated physician) (Include title) Exhibit 7-72 - Confirmed Quality Concern Model Notice – (Rev. 4, 07-18-03) YOUR LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Patient Name Health Insurance Claim (HIC) Number Provider Name Provider Number Date of Admission/Service Medical Record Number (if known) Dear: The (QIO name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review medical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our primary purpose is to identify areas where care can be improved and to feed back information to physicians and providers. This peer review is intended to be a collegial interaction with the goal of improving patient care. We appreciate the time and effort involved in your cooperation with our review activities. A QIO physician reviewer has completed review of the care provided to (name of patient) at (name of provider) for (specify the procedure, treatment, condition, and/or services). Based on a careful review of the information contained in the medical record and any additional information provided during the opportunity for discussion, the physician reviewer has reached the following determination. (Summarize the case findings and concerns, including your preferred course of action, from the initial/final review decision portion of the PRAF.) We are entering this information into our database for pattern analysis. On an ongoing basis we analyze patterns of care involving quality concerns or positive outcomes that may have significance beyond a single episode. Be assured that if a pattern involving a quality concern is identified, we will provide both you and (name (See NOTEs below)) ample opportunity to discuss the concern with us. NOTE: If the notice is addressed to the provider, insert the name of the physician(s). NOTE: If the notice is addressed to the physician, insert the name of the provider. Do not specify any other physicians you may also be notifying. We are also notifying (name (See NOTEs above)) of our final determination. If you or (name (See NOTEs above)) disagree with our quality of care concern determination, either party may request a re-review. To request a re-review, you must submit your request in writing within 30 days from receipt of this notice. Therefore, we must receive your request by (date). Your written request should include the reason for your dissatisfaction with our determination and any additional information you might wish to submit. Send your written request to: QIO Name Address Telephone Number The information in this notice is confidential and may be re-disclosed only in accordance with Federal regulations found in 42 CFR 476.107 and 108. Sincerely, Medical Director (or designated physician) (Include title) Exhibit 7-73 - Re-review Upheld Quality Concern Model Notice – (Rev. 4, 07-18-03) YOUR LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Patient Name Health Insurance Claim (HIC) Number Provider Name Provider Number Date of Admission/Service Medical Record Number (if known) Dear: The (QIO name) is the Quality Improvement Organization (QIO) authorized by the Medicare program to review medical services provided to Medicare patients in the State of ____________________. By law, we review Medicare cases to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting. Our primary purpose is to identify areas where care can be improved and to feed back information to physicians and providers. This peer review is intended to be a collegial interaction with the goal of improving patient care. We appreciate the time and effort involved in your cooperation with our review activities. As a result of a (date) request for a re-review, we have conducted a complete review of the care provided to (name of patient) at (name of provider) for (specify the procedure, treatment, condition, and/or services) to determine whether our original confirmed quality of care concern determination was correct. This re-review was performed by a QIO physician reviewer who was not involved in the original quality concern determination. Based on a thorough re-examination of all the information contained in the medical record and consideration of any additional information provided by you and the (insert either "provider" or "physician"), the physician reviewer has reached the following determination. Summarize the case findings and concerns, including your preferred course of action, from the reconsideration/re-review portion of the PRAF (PRAF 3). We are entering this information into our database for pattern analysis. On an ongoing basis we analyze patterns of care involving quality concerns or positive outcomes that may have significance beyond a single episode. Be assured that if a pattern involving a quality concern is identified, we will provide both you and (name (See NOTEs below)) ample opportunity to discuss the concern with us. NOTE: If the notice is addressed to the provider, insert the name of the physician(s). NOTE: If the notice is addressed to the physician, insert the name of the provider. Do not specify any other physicians you may also be notifying. The Social Security Act does not provide for further appeal of this determination. We are also notifying (name (See NOTEs below)) of our re-review determination. NOTE: If the notice is addressed to the provider, insert the name of the physician(s). NOTE: If the notice is addressed to the physician, insert the name of the provider. Do not specify any other physicians you may also be notifying. The information in this notice is confidential and may be re-disclosed only in accordance with Federal regulations found in 42 CFR 476.107 and 108. Sincerely, Medical Director (or designated physician) (Include title) Exhibit 7-74 - Examples of Potential Quality Concern Scenarios – (Rev. 4, 07-18-03) The QIO must make a determination as to which physicians will receive preliminary notices depending on the unique circumstances of each case. Examples of possible scenarios follow: Scenario 1:  The attending physician admits and follows the patient.  The admission is medically necessary.  At some point during the hospitalization, a surgeon performs a procedure.  There is a question as to the medical necessity of the procedure. Notices go to:  The provider;  The attending physician; and  The surgeon. Scenario 2:  The attending physician admits and follows the patient.  At some point during the hospitalization, a surgeon performs a procedure.  The patient was admitted solely for the performance of the procedure.  There is a question as to the medical necessity of the procedure. Notices go to:  The provider;  The attending physician; and  The surgeon. Scenario 3:  The attending physician admits and follows the patient.  At some point during the hospitalization, a surgeon performs a procedure.  There is a technical error during the procedure with no apparent complications. Notices go to:  The provider; and  The surgeon. Scenario 4:  The attending physician admits and follows the patient.  At some point during the hospitalization, a surgeon performs a procedure.  There is a technical error during the procedure with apparent complications. Notices go to:  The provider; and  The surgeon. Scenario 5:  The attending physician admits and follows the patient.  At some point during the hospitalization, a surgeon performs a procedure.  The patient apparently suffers a cerebral vascular accident (CVA) during the procedure.  An hour's worth of vital signs were apparently not taken during the procedure. Notices go to:  The provider;  The surgeon;  The anesthesiologist; and  The physician who medically cleared the patient for surgery, if the QIO identified a concern with the medical clearance. Scenario 6:  The attending physician is an internist.  During the course of the hospitalization, a cardiologist and a pulmonologist are also following.  The patient experiences an episode of severe respiratory distress.  All three physicians are called and respond.  The orders to treat the episode are apparently inadequate and are signed by the internist. Notices go to:  The provider;  The attending physician; and  The pulmonologist and/or the cardiologist, only if the QIO believes that they can materially contribute to the resolution of the potential quality concern. Scenario 7:  The attending physician is an internist.  During the course of the hospitalization, a cardiologist and a pulmonologist are also following.  The patient experiences an episode of severe respiratory distress.  All three physicians are called and respond.  The orders to treat the episode are apparently inadequate and are signed by the pulmonologist. Notices go to:  The provider;  The pulmonologist; and  The attending physician. Scenario 8:  The attending physician is an internist.  During the course of the hospitalization, a cardiologist and a pulmonologist are also following.  The patient experiences an episode of severe respiratory distress.  The internist responds.  The orders to treat the episode are apparently inadequate and are signed by the internist. Notices go to:  The provider; and  The attending physician. Scenario 9:  The attending physician is an internist.  During the course of the hospitalization, a cardiologist and a pulmonologist are also following.  The patient experiences an episode of severe respiratory distress.  The pulmonologist responds.  The orders to treat the episode are apparently inadequate and are signed by the pulmonologist. Notices go to:  The provider;  The pulmonologist; and  The attending physician, if, in the QIO's judgment, he/she can materially contribute to the resolution of the potential quality concern (e.g., if the attending physician saw the patient very soon after the episode and failed to countermand the orders in question).