CMS Pub. 100-10, ch. 7, § 7050

The Medicare+Choice Organization (M+CO) or the hospital (as delegated) issues the

NODMAR with the physician's concurrence to the M+C enrollee. The physician's

concurrence acknowledges agreement that inpatient hospital care is no longer necessary.

A. When the M+CO Issues the NODMAR

The M+CO issues the NODMAR to the M+C enrollee once the required concurrence of

the physician who is responsible for the enrollee's hospital care has been obtained (See 42

CFR 422.620(b)).

B. When Hospital Accepts Delegation

If the M+CO allows the hospital to make the non-coverage/discharge determination

(delegation), the hospital must obtain concurrence from the contracting physician

responsible for the enrollee's hospital care or of another physician as authorized by the

M+CO (see 42 CFR 422.620(d)).

C. Content of NODMAR

The NODMAR must include the following information:

 The reason why inpatient hospital care is no longer needed;

 The effective date of the enrollee's liability for continued inpatient care; and

 The enrollee's appeal rights.

D. QIO Responsibility -- You are not required to review or educate the plans regarding

the content of the NODMAR. However, if you find an inappropriate NODMAR (e.g.,

the liability date is missing) during the course of your review, you are expected to report

such findings to the CMS RO plan manager through your Project Officer.

7055 - Medicare Enrollee Request for Quality Improvement

Organization (QIO) Immediate Review - (Rev. 4, 07-18-03)

A. Enrollee Request

If the Medicare enrollee or his/her representative disagree with the NODMAR and the

Medicare enrollee remains in the hospital, he/she may request (no 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 (See 42 CFR 422.622).

NOTE: In cases involving a M+CO located outside the QIO review area, the request for

immediate QIO review must be made to and reviewed by the QIO that has the agreement

(under 42 CFR 476.78) with the hospital treating the enrollee, not the QIO with the

agreement with the M+CO. This means regardless of whether the determination was

made by a M+CO or a hospital, the QIO that has the agreement with the M+CO is not

involved (see chapter 3, for the Memorandum of Agreement requirement related to

NODMAR).

B. M+C Notification

On the day that you receive the enrollee's request for an immediate review, you must

notify the M+CO.

C. QIO Request for Medical Information

The M+CO must take the following actions once an enrollee's request for an immediate

review is confirmed:

 The M+CO must supply any information that you require to conduct your review.

This information must be made available to you, by telephone or in writing, by

close of business of the first full working day immediately following the day the

enrollee submits the request for review.

 The M+CO must contact the hospital and request that the enrollee's medical

records and other pertinent information be sent to you by close of business of the

first full working day immediately following the organization's request.

D. QIO Immediate Review

 Solicitation of Views -- You must solicit the view of the enrollee or his/her

representative that requested the immediate review (See §7020).

 QIO Review Determination -- Once you have received all the necessary

information from the hospital or the organization or both (e.g., medical records),

review the case and notify the enrollee, the hospital, and the M+CO of your

determination by close of business of the first working day following receipt of all

pertinent information. Make your notification initially by telephone and follow

up with a written notification (See §7015.B.1).

E. Enrollee Liability Protection

If the M+CO authorized coverage of the inpatient admission directly or by delegation (or

the admission constitutes emergency or urgently needed services as described in 42 CFR

422.2 and 422.112(c)), the organization continues to be financially responsible for the

costs of the hospital stay when a timely appeal is filed until noon of the calendar day

following the day you notify the enrollee of your decision.

NOTE: The hospital may not charge the M+CO (or the enrollee) if it was the hospital

(acting on behalf of the enrollee) that filed the request for immediate QIO review and the

QIO upholds the non-coverage determination made by the M+CO.

F. Untimely Request for QIO Immediate Review

If the request for an immediate review is not filed timely by the Medicare enrollee or

his/her representative, do not review the case.

Instructions found at 42 CFR 422.622(a)(2) provide an enrollee who fails to make a

timely request for QIO review the fall-back option of requesting an expedited

reconsideration from the M+CO. You must notify the beneficiary that his/her case is

being referred to the M+CO for an expedited reconsideration (72 hour fast review).

NOTE: The beneficiary is not entitled to subsequent review by the M+CO under the

regulations at 42 CFR 422.582 and 42 CFR 422.584 once a QIO review is requested.

Instead, the beneficiary has further appeal rights under 42 CFR 478.

G. NODMAR Rescinded

If the M+CO notifies you that the NODMAR has been rescinded after requesting the

medical records, you should:

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

rescinding the NODMAR);

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

appropriately in rescinding the notice;

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

hospital’s action and that he/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 NODMAR.

Because you do not monitor the issuance of the NODMAR, you are to refer to the Project

Officer any single case where a NODMAR has been rescinded.

7100 - Authority - (Rev. 4, 07-18-03)

Deny claims in accordance with 42 CFR 476.83 when you determine that health care

services furnished or proposed to be furnished to a beneficiary are non-covered because

they are not medically necessary and reasonable (§1862(a)(1) of the Act) or constitute

custodial care (§1862(a)(9) of the Act). In addition, QIOs may deny Part A claims when

a hospital circumvents the Prospective Payment System (PPS) through unnecessary

admissions or readmissions in accordance with §1886(f)(2) of the Act (Deny claims only

as specified in §4255). If, as a result of DRG validation, you determine that the diagnosis

and/or procedures billed by the hospital should be changed and the DRG is affected,

change the DRG assignment in accordance with 42 CFR Part 476. Provide written

notification of initial denial determinations and DRG assignment changes to all affected

parties as specified in 42 CFR 476.94.

7101 - Types of Denial Determinations - (Rev. 4, 07-18-03)

Initial and technical denials apply to services/items furnished in acute/specialty hospitals

(including swing beds) and hospital outpatient/ambulatory surgical centers, hereafter

referred to as providers.

A. Initial Denials

Initial denial determinations are subject to reconsideration and further appeals. These

types of denials include:

 Preadmissions;

 Admission;

 Continued-stay;

 Circumvention of PPS;

 Services/procedures; and

 Cost outliers (and day outliers, if applicable).

NOTE: Render an initial denial determination only after you have afforded the

provider/practitioner an opportunity for discussion.

B. Technical Denials

Technical denial determinations are not subject to reconsideration and further appeals,

but may be subject to re-review/reopening (See §7102.B). These types of denials

include:

 Medical record not submitted timely (42 CFR 476.90(b)); and

 Billing errors (including cost outlier denials due to duplicative billing for services

or for services not actually furnished or not ordered by the physician).

NOTE: Opportunity for discussion does not apply to technical denials.

C. DRG Assignment Changes

The DRG assignment changes may result from your correction of technical coding errors

or your correction of diagnostic, procedure, or discharge status information and the

related codes. Changes to the DRG coding information are not subject to reconsideration

and further appeals. These changes are, however, subject to re-review/reopening when

they result in a revised DRG assignment and lower payment (See 42 CFR 478.15 and

478.48).

NOTE: Render DRG assignment changes only after you have afforded the

provider/practitioner an opportunity for discussion.

7102 - Denial and Reopening Timeframes - (Rev. 4, 07-18-03)

A. Initial Denial Determinations and DRG Assignment Changes

Render an initial denial determination or DRG assignment change within one year of the

payment date of the claim containing the service(s) in question (see 42 CFR

476.96(a)(1)).

If the RO approves the action in writing, you may render an initial denial determination

or DRG assignment change after one year but within four years of the payment date of

the claim containing the service(s) in question (See 42 CFR 476.96(b)(1)).

NOTE: These timeframes also apply to technical denial determinations.

Issue notices to all appropriate parties as specified in §§7105-7115. Process

reconsideration requests as specified in §§7400-7440.

B. Reopening of Initial Denial Determinations and DRG Assignment Changes

Conduct reopening as specified below. Issue notices to all appropriate parties if the

reopening results in a change in your initial denial determination or a change in DRG

assignment (See §§7105-7115).

 Reopening Within One Year -- You may reopen an initial denial determination or

DRG assignment change within one year of the date of your decision (See 42

CFR 476.96(a)(2)).

NOTE: You may reopen a technical denial determination within one year of the date of

your decision when you deny the claim for lack of medical record information and the

information is subsequently provided (Do not reopen any other types of technical denial

determinations).

 Reopening After One Year But Within Four Years -- You may reopen an initial

denial determination or DRG assignment change after one year but within 4 years

of the date of your decision if (See 42 CFR 476.96(b)(2)):

• You receive additional information on the patient's condition that affects

the basis of the prior decision;

NOTE: The additional information is generally part of the medical record for the stay in

question. There may be exceptions such as additional information related to other

hospital stays, physician notes, etc. Addendum orders (i.e., where the physician did not

order a service/procedure and retroactively writes such an order) are not considered

"additional information."

• Reviewer error occurred in interpretation or application of Medicare

coverage policy or review guidelines;

• There is an error apparent on the face of the evidence upon which the

initial denial or DRG assignment change was based; or

• There is a clerical error in the statement of the initial denial determination

or DRG assignment change.

NOTE: You may reopen a technical denial determination after one year but within four

years of the date of your decision when you deny the claim for lack of medical record

information and the information is subsequently provided (Do not reopen any other types

of technical denial determinations).

7105 - Notification of Denial - (Rev. 4, 07-18-03)

Provide written notification of initial denials, technical denials, and DRG assignment

changes to all affected parties, as appropriate (See Exhibits 7-22 through 7-34).

A. Parties to be Notified - Provide Written Notice to:

 The beneficiary or his/her representative. Do not notify the beneficiary or his/her

representative of DRG assignment changes or denials based on circumvention of

PPS or billing errors;

 The attending physician or other attending health care practitioner. Do not notify

the individual of circumvention of PPS denials. You are only required to notify

the individual of changes to DRG coding information when the changes revise the

DRG assignment;

 The provider (if known, include in preadmission/pre-procedure cases). You and

the provider are to specify in your memorandum of agreement who will receive

your notices for the provider. You are only required to notify the provider of

changes to DRG coding information when the changes revise the DRG

assignment; and

 The intermediary/carrier. If you notify the intermediary/carrier electronically of

the denial determination (including limitation of liability determinations, if

applicable), you need not provide a hardcopy of the notice. Notify the

intermediary of DRG assignment changes. Do not notify the intermediary of

coding changes that do not affect the DRG assignment.

B. Issuance of Notice

Issue notices on a case-by-case basis as follows:

 One notice addressed to the beneficiary or his/her representative with copies to

the provider, attending physician, and intermediary/carrier; or

 One notice addressed to the provider (when the beneficiary or his/her

representative is not notified) with copies to the attending physician and

intermediary/carrier (Do not send a copy to the attending physician for

circumvention of PPS denials).

If a case is selected for retrospective review and you find that a HINN was issued, do not

issue a denial notice if you agree with the provider's decision and the beneficiary was not

liable for charges (Issue a notice for all HINN cases reviewed at the beneficiary's or

provider's request).

C. Determination of Beneficiary Address

Ensure that denial notices mailed to beneficiaries who are no longer in the facility are

sent to the correct address. To assist you in determining the beneficiary's correct address,

CMS can provide you with copies of the Carrier Alphabetic State File (CASF) on

microfilm or the Beneficiary Eligibility Status Tapes (BEST) on magnetic tape. Use of

these files is optional. To obtain copies on an ongoing basis, send a written request to

your RO project officer. There is no charge to you for these files.