CMS Pub. 100-04, ch. 1, § 150.3.1

Expedited determination notices are required prior to discharge when Medicare covered

care has been occurring for some type of duration, such as a stay in an inpatient facility,

or a period of services delivered under a plan of care supported by a physician order.

Generally, intermittent items or services covered under Part B do not trigger the right to

expedited determinations, since there is no continuous care to end. Expedited

determinations are available to beneficiaries for each of the specified provider types as

follows:

HHAs: Provider initiated discharges for coverage reasons from HH services under a

home health plan of care (types of bill 32x and 33x) are subject to expedited

determination notices. Home health services billed on a 34x type of bill are included if

there is a therapy plan of care, but not when the HHA is acting as a durable medical

equipment supplier in one-time or sporadic delivery of equipment.

SNFs: Provider initiated discharges for coverage reasons associated with SNF and swing

bed inpatient claims (types of bill 18x, 21x and 22x) are subject to expedited

determination notices.

Hospices: Provider initiated discharges for coverage reasons from hospice services

(types of bill 81x and 82x), whether in inpatient or home care settings, are subject to

expedited determination notices. Even though revocation represents an end of covered

hospice care, it cannot trigger an expedited determination since it is the beneficiary’s, not

the provider’s, choice to revoke. Hospice discharges related to qualification/coverage

specific to the benefit would be rare cases where a beneficiary previously certified as

terminally ill is judged no longer to be terminal.

CORFs: Provider initiated terminations of all covered CORFs services (type of bill 75x)

provided under a therapy plan of care are subject to expedited determination notices.

CORF services not provided under a plan of care, such as injections, are not included.

Therapy services provided by outpatient rehabilitation facilities (type of bill 74x) or

therapy services in hospital outpatient departments are not included.

Expedited determinations notices are not required when discharge is unrelated to

coverage.