CMS Pub. 100-04, ch. 1, § 150.3.3

Expedited Determinations

(Rev.13026, Issued: 12-27-24, Effective: 10-11-24 , Implementation: 02-15- 25)

As noted above, the outcome of expedited determinations and reconsiderations will be

reported on Medicare claims to assure A/B MAC (A) adjudication of claims is consistent

with QIO/QIC decisions. Note that the expedited review process is always completed

prior to billing, and therefore does not directly affect established billing procedures, even

demand billing, other than the use of indicators described below.

Special indicators are used on claims to reflect the outcome of QIO expedited

determinations and QIC reconsiderations. Before the creation of the expedited review

process, QIO related determinations were reflected only on hospital claims. A set of

condition codes were used to reflect these determinations. These codes, C1- C7, are

known as the QIO approval indicator codes.

With the advent of the expedited determination process, these QIO approval indicators

are relevant to types of bill other than inpatient hospital claims. The QIO approval

indicator codes described below are valid for Medicare billing on the following types of

bill:

18x, 21x, 22x, 23x, 32x, 33x, 34x, 75x, 81x, 82x.

Since QIO expedited decisions and QIC reconsideration decisions have the same effect

on providers and beneficiaries, the same QIO approval indicator codes will be used to

report a decision by either entity. Providers should note that no indicators are required on

discharge claims in the case where a generic notice is provided and the beneficiary does

not request an expedited determination.

A Reporting of QIO/QIC Decisions Upholding a Discharge

Providers must also report indicators on claims when they receive notification of

decisions which uphold the provider’s decision to discharge the beneficiary from

Medicare covered care. In these cases, providers submit a discharge claim for the billing

period that precedes the determination according to all applicable claims instructions plus

one additional data element. Providers must annotate these claims with condition code

C4, defined as “Services Denied.”

Beneficiaries are protected from liability for the period from the delivery of the expedited

notice, usually two days before the end of coverage, to the end of the covered period

written on the notice if the beneficiary requests an expedited determination timely. If the

beneficiary does not request the determination timely, or if the determination process at

the QIO is delayed, the beneficiary may be liable for services provided from the day after

the end of the covered period until the date of the actual discharge.

In cases where the beneficiary may be liable, in addition to reporting condition code C4

providers must also report occurrence span code 76, defined as “patient liability period,”

along with the days of liability that have been incurred. Line items with dates of service

falling within this patient liability period are reported with noncovered charges and, if

they require HCPCS coding, with modifier –TS. A/B MAC (A) will deny these lines and

hold the beneficiary liable.

In certain cases, an Advance Beneficiary Notice (ABN) may be issued simultaneously or

immediately following the issuance of an expedited determination notice. These ABNs

would pertain to continued services that the beneficiary wishes to receive despite the

provider’s intent to discharge the beneficiary. Any required physician orders continue to

be needed for the services to continue. If these ABN situations result in a beneficiary’s

request for a demand bill to Medicare regarding continuing services after the QIO/QIC

has upheld the discharge, providers must report condition code C4 on the demand bill.

The demand bill must otherwise be prepared according to all other applicable

instructions.

B Reporting of QIO/QIC Decisions Not Upholding a Discharge

When providers are notified of QIO/QIC decisions that authorize continued Medicare

coverage and do not specify a coverage ending date, they must submit a continuing claim

for the current billing or certification period according to all claims instructions for the

applicable type of bill, plus a single additional data element. Providers must annotate

these claims with condition code C7, which is defined “QIO extended authorization.”

This indicator will alert A/B MAC (A) that coverage of the services on the claim has

already been subject to review.

In the circumstance, expected to be rare, when providers are notified of QIO/QIC

decisions which authorize continued Medicare coverage only for a limited period of time,

they must submit claims as follows:

• If the time period of coverage specified by the QIO/QIC extends beyond the end of

the normal billing or certification period for the applicable type of bill, providers

submit a continuing claim for that period according to all applicable claims

instructions plus two additional data elements. Providers must annotate these claims

with condition code C3, which is defined “QIO partial approval” and with occurrence

span code M0, which is defined “QIO approved stay dates”, along with the following

dates—the beginning date of the coverage period provided by the QIO/QIC, and the

statement through date of the claim.

• If the time period of coverage specified by the QIO/QIC does not extend to the end of

the normal billing or certification period for the applicable type of bill, providers

submit a discharge claim according to all applicable claims instructions plus two

additional data elements. Providers must annotate these claims with condition code

C3, which is defined “QIO partial approval” and with occurrence span code M0,

which is defined “QIO approved stay dates” and the dates provided by the QIO/QIC.

NOTE: Regarding any decision that does not uphold a discharge, QIO/QIC decisions

authorizing extended coverage cannot authorize delivery of services if there are not also

the required physician orders needed to authorize the care.

C Billing Beneficiaries in Cases Subject to Expedited Determinations

Providers should note a significant difference between the use of expedited determination

notices and the use of ABNs. As described in Claims Processing Manual, Chapter 1,

section 60.3.1, in ABN or HHABN situations, all providers other than SNFs can bill

beneficiaries for services subject to a demand bill while awaiting a Medicare

determination on the coverage of the services. The same is not true in expedited

determination situations. When a beneficiary requests an expedited determination timely,

no funds may be collected until the provider receives notification of the QIO/QIC

decision.

D Reporting Provider Liability Situations

Providers may be liable as a result of two specific situations in the expedited review

process:

(1) if the provider is not timely in giving information to the QIO; and

(2) if the provider does not give valid notice to the beneficiary.

Since both these events occur after the point the provider has already determined

discharge is imminent, there may be no actual liability, since there may be no medical

need for additional care. However, if services are required, and either of these liability

conditions apply, such services should be billed as noncovered line items using the –GZ

modifier, which indicates the provider is liable, consistent with Section 60.4.2 of this

chapter.