CMS Pub. 100-10, ch. 7, § 7010

You are required to monitor the content of the HINN to determine whether the

information is accurate/appropriate. The HINN to the beneficiary or his/her

representative must conform to the content (but need not be a duplicate) of the model

letters contained in Exhibits 1 through 10 of §414.11 of the Hospital Manual (See §414.5

for instructions concerning the content of hospital HINNs).

7015 - Beneficiary Request for Review of Hospital-Issued Notice of Non-coverage by a QIO - (Rev. 4, 07-18-03)

A. Preadmission/Admission HINN

When a beneficiary or his/her representative requests review of a preadmission or

admission HINN, review any records pertaining to health care services furnished.

Include records pertaining to any inpatient hospital services provided or proposed to be

provided to the Medicare beneficiary whether or not, in the hospital's view, the services

are covered (See 42 CFR 476.88(a) and §§1154 and 1156 of the Act).

 Immediate Review -- If the beneficiary or his/her representative disagrees with

the hospital preadmission notice, he/she may request your review, by telephone or

in writing, within 3 calendar days of receipt of the HINN. If admitted, the

beneficiary or his/her representative may request your review at any point during

the stay. In either situation review the case within 2 working days following the

beneficiary's or his/her representative's request, and issue either a denial notice or

a notice explaining that the care would be, or is, covered.

 Review After Discharge or When Beneficiary Was Not Admitted to Hospital --

The beneficiary or his/her representative may request review within 30 calendar

days after receipt of the notice. Complete this review within the timeframe

specified for any retrospective review (See §4540). Once your review is

completed issue either a denial notice or a notice explaining that the care is

covered.

B. Continued-stay HINN

The beneficiary or his/her representative may request your review, as described below,

when the hospital issues a continued-stay notice of non-coverage with the concurrence of

the attending physician (see §7005.B.1). If the hospital issues a continued-stay notice of

non-coverage with your concurrence, the beneficiary may request a reconsideration of

your determination (see §7040).

 Beneficiary Request for QIO Immediate Review of a HINN -- If the beneficiary

or his/her representative disagrees with the HINN and remains in the hospital,

he/she may request (not later than noon of the first working day after the day the

notice was received) an immediate review by you. This request for review may

be made by telephone or in writing.

• The hospital must provide the medical records you require by close of

business of the first working day after the date that the beneficiary

receives the notice. Develop a procedure with the hospital that will ensure

timely receipt of records (e.g., express mail service).

• When a beneficiary or his/her representative requests your review,

perform the review regardless of whether or not the hospital charges for

continued-stay, or the beneficiary is liable for such care.

 Prior to rendering a determination, solicit the views of the

beneficiary or his/her representative, hospital, and attending

physician (See §7020).

 Complete the requested review and notify the beneficiary or

his/her representative, the attending physician, and the hospital of

your determination (whether adverse or favorable) within one full

working day after the date of receiving the request and the required

medical records.

• Make your notification initially by telephone and follow up with a written

notification either:

 Disagreeing with the hospital's decision (i.e., notifying the

beneficiary that he/she requires covered care); or

 Agreeing with the hospital's determination (i.e., issuing your initial

denial notice). In addition, the beneficiary will also receive the

HINN.

• Document the telephone notification (e.g., time of call, information

presented, and names of parties contacted). Retain this documentation in

your case files.

 Other Review While the Beneficiary Is In the Hospital -- If the beneficiary or

his/her representative does not request your review by noon of the first working

day after receipt of the HINN and remains in the hospital, he/she may still request

your review at any point during the stay. The request may be made by telephone

or in writing. Review the case within 2 working days following the beneficiary's

or his/her representative's request, and issue either a denial notice or a notice

explaining that the care is covered.

 Review After Discharge -- If the beneficiary is discharged from the hospital,

he/she or his/her representative may still request review within 30 calendar days

after receipt of the HINN or at any time, for good cause. Complete this review

within 30 calendar days of receipt of the medical records, and issue either a denial

notice or a notice explaining that the care is covered.

NOTE: After a beneficiary has exhausted all of his/her hospital benefit days (and the

length of stay has passed the day outlier threshold), you are not obligated to review the

hospital's decision regarding the beneficiary's need for continued hospital care for those

days. Any advisory determination you make related to these exhausted benefit days is

not subject to your reconsideration process (and further appeal rights) as it is not an initial

determination. Your initial determination pertaining to inpatient days prior to exhausting

benefit days or within the outlier threshold is binding on all parties (i.e., you can approve

or deny Medicare payment, but it is still subject to appeal by the beneficiary).

C. Continued-stay HINN Rescinded -- If the hospital notifies you that the HINN has

been rescinded after requesting the medical records:

 Instruct the hospital to submit the medical records (including a copy of the notice

rescinding the HINN);

 Review the medical record and determine whether or not the hospital acted

appropriately in rescinding the notice;

 Notify the beneficiary that the HINN was rescinded if you agree with the

hospital’s action and that he or she should have received a written notification

from the hospital; and

 Issue your written initial determination (including a determination of the

beneficiary’s liability for payment under §1869 of the Act) if you disagree with

the hospital’s rescinded HINN.

7020 - Solicitation of Views Regarding Hospital-Issued Notice of Non-coverage - (Rev. 4, 07-18-03)

A. Beneficiary's Views

When you conduct a review either because the beneficiary or his/her representative

requests one (See §7015.B.1) or the hospital requests your review because the attending

physician does not agree with its decision to issue a notice of non-coverage (See

§7005.B.2), solicit the views of the beneficiary or his/her representative. This may be

done by telephone. Present information solicited to the physician reviewer for use in the

review. Also, make the information part of your case file. Solicit the views of the

beneficiary or his/her representative at the same time as his/her telephone request for

review to minimize the burden on the beneficiary.

Make every attempt to contact the beneficiary or his/her representative within the

timeframe allotted for review completion. If the beneficiary or his/her representative

cannot be contacted by the end of the first full working day after the request for review

and receipt of the medical record, make your review determination without the

beneficiary's or his/her representative's views. Retain documentation of your attempts to

contact the beneficiary/representative.

B. Discussion With the Hospital and Attending Physician

Give the attending physician and provider the opportunity to discuss the case prior to

your determination, whether it will be adverse or favorable. Make every attempt to

contact the hospital and attending physician before you make a determination.