US · guidance
CMS Pub. 100-04, ch. 30, § 450.5.6
Make Determination and Notify Required Parties
For timely requests (received before the beneficiary leaves the hospital):
The BFCC-QIO must make its determination no later than one calendar day after it
receives all requested pertinent information from the hospital.
For untimely requests (received after the beneficiary leaves the hospital):
The BFCC-QIO must make its determination no later than two calendar days after it
receives all requested pertinent information from the hospital.
The BFCC-QIO must perform the following actions for timely and untimely requests.
1. Notify the beneficiary, the hospital, and SNF (if applicable) of its determination.
This notification must include the rationale for the determination and an
explanation of Medicare payment consequences and beneficiary liability.
2. Inform the beneficiary of the right to an expedited reconsideration by the BFCC-QIO and how to request a timely expedited reconsideration.
3. Make its initial notification via telephone and follow up with a written
determination letter.
NOTE: If the BFCC-QIO does not receive supporting information from the hospital, it
may make its determination based on the evidence at hand or defer a decision until it
receives the necessary information.
History
(Rev. 12934; Issued: 10-31-24; Effective: 11-15-24; Implementation: 02-14-25)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
b7c085ad8248ff2a6734431eabb8e3daa3df2f1032913e748585c06d734178a6
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