CMS Pub. 100-04, ch. 30, § 240.6

Hospital Issued Notice of Noncoveage

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

Hospital Identifier

Preadmission or Admission Hospital-Issued Notice of Noncoverage (HINN)

Model Language

Name of Patient: ____________________Name of Physician:____________________

Patient ID Number: __________________Date Issued: _________________________

We believe that Medicare is not likely to pay for your admission for

_____________________(specify service or condition)__________________ because:

____it is not considered to be medically necessary

____it could be furnished safely in another setting

____other________________________________________________.

However, this notice is not an official Medicare decision.

If you disagree with our finding:

• You should talk to your doctor about this notice and any further health care you may

need.

• You also have the right to an appeal, that is, an immediate review of your case by a

Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by

Medicare to make a formal decision about whether your admission is covered by

Medicare. See page 2 for instructions on how to request a review and contact the

QIO.

• If you decide to go ahead with the hospitalization, you will have to pay for:

________________________________________________________________1

•

CONTINUED ON PAGE 2

1 For preadmission notices, insert: "customary charges for all services furnished during the stay,

except for those services for which you are eligible under Part B."

For admission notices issued not later than 3:00 P.M. on the date of admission, insert:

"customary charges for all services furnished after receipt of this hospital notice, except for those

services for which you are eligible under Part B." (If these requirements are not met, insert the

liability phrase below.)

For admission notices issued after 3:00 P.M. on the day of admission, insert: "customary

charges for all services furnished on the day following the day of receipt of this notice, except for

those services for which you are eligible to receive payment under Part B."

If you want an immediate review of your case:

________________(insert one of the following as appropriate)_____________

Preadmission:

• Call the QIO immediately at the number listed below, but no later than 3 calendar days

after you receive this notice. If you are admitted, you may call the QIO at any point in the

stay.

Admission:

• Call the QIO immediately at the number listed below or you may call the QIO at

any point during your stay.

• You may also call the QIO for quality of care issues.

QIO Contact Information: _______(insert name of QIO in bold)________________

_______(insert telephone number of QIO)_____________

If you do not want an immediate review:

• You may still request a review within 30 calendar days from the date of receipt of

this notice by calling the QIO at the number below.

Results of the QIO Review:

• The QIO will send you a formal decision about whether your hospitalization is

appropriate according to Medicare’s rules, and will tell you about your reconsideration

and appeal rights.

° IF THE QIO FINDS YOUR HOSPITAL CARE IS COVERED, you will be

refunded any money you may have paid the hospital except for any applicable

copays, deductibles, and convenience items or services normally not covered by

Medicare.

° IF THE QIO FINDS THAT YOUR HOSPITAL CARE IS NOT COVERED, you

are responsible for payment for all services beginning on ______(specify

date)____. (see footnote1 on page 1).

For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048.

_____________________________________________________________________

Please sign your name, the date and time. Your signature does not mean that you agree with this

notice, just that you received the notice and understand it.

______________________________________ __________ ________

Signature of Patient or Representative Date

Time