CMS Pub. 100-04, ch. 30, § 240

(HINN)

(Rev. 1257, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)

Regulations found at 42 CFR Part 476.71 require QIOs to review the medical necessity of

hospital discharges and admissions, in addition to other requirements specified in that

section of the regulation. Therefore, a beneficiary has a right to request an expedited

review by the QIO when a hospital (acting directly or through its utilization review

committee) has determined at the time of preadmission or admission, that the beneficiary

is facing a non-covered hospital stay because the services are not considered to be

reasonable and necessary in this case, the services could be safely provided in another

setting, or the care is considered custodial in nature.

The utilization review committee or the hospital may issue a preadmission/admission

HINN. QIOs may also issue such notices after having been contacted by a hospital

regarding care believed to be medically unnecessary, inappropriate, or custodial. The

hospital need not obtain the attending physician's concurrence, or the QIO's, prior to

issuing the preadmission/admission HINN. This also applies to direct admissions to

swing beds (i.e., the beneficiary is admitted to the swing bed when the hospital

determines that the beneficiary does not need hospital-level care, but instead needs only

skilled nursing (SNF) or custodial nursing (NF) level services).