KEYS TO SUCCESS IN ISSUING HOSPITAL ISSUED NOTICES OF NON-COVERAGE HINNs Unlocking Opportunities

1. KEYS TO SUCCESS IN ISSUING HOSPITAL ISSUED NOTICES OF NON-COVERAGE (HINNs)�Unlocking Opportunities� Today, we�re going to talk about Hospital-Issued Notices of Non-Coverage, better known as HINNS and Notices of Discharge and Medicare Appeal Rights, called NODMARS (Discuss NODMARS only if they deal with Medicare HMOs). Refer to Guidelines Book. Location of PowerPoint presentation in Windows Explorer: T/8SOW/BeneProtection/HINNs & NODMARsToday, we�re going to talk about Hospital-Issued Notices of Non-Coverage, better known as HINNS and Notices of Discharge and Medicare Appeal Rights, called NODMARS (Discuss NODMARS only if they deal with Medicare HMOs). Refer to Guidelines Book. Location of PowerPoint presentation in Windows Explorer: T/8SOW/BeneProtection/HINNs & NODMARs

2. Online Location www.aqaf.com Professionals Utilization Review & Coding Resources Guidelines For Issuing HINNs & NODMARs You can find the most recent copy of this book online. You can go to this website and download the notices to have the most updated verbiage, i.e. QIO versus PRO and AQAF�s current address.You can find the most recent copy of this book online. You can go to this website and download the notices to have the most updated verbiage, i.e. QIO versus PRO and AQAF�s current address.

3. Reminders/Updates Important Message from Medicare www.cms.hhs.gov/medicare/bni NODMARs are to be given to people who belong to one of the Medicare Advantage Plans VIVA Medicare Complete Seniors First Blue Advantage ( BC/BS plan, which began July 1, 2005) The Important Message from Medicare should be given to every Medicare patient at or about the time of admission. This starts the process because it lets the patient know that they can ask for an appeal if they feel that they are not ready to be discharged. We have noticed in some medical records that the Important Message from Medicare is old, i.e. it uses �PRO� instead of �QIO� and also has AQAF�s old address. These need to be replaced ASAP to provide the beneficiary with accurate information; therefore, please ask your Admissions Dept. to replace these by going to the website listed on the slide to use the new ones. The website also gives instructions on using the Important Message from Medicare. Blue Advantage: You may have seen a large increase in these kinds of patients as of July 1, 2005.The Important Message from Medicare should be given to every Medicare patient at or about the time of admission. This starts the process because it lets the patient know that they can ask for an appeal if they feel that they are not ready to be discharged. We have noticed in some medical records that the Important Message from Medicare is old, i.e. it uses �PRO� instead of �QIO� and also has AQAF�s old address. These need to be replaced ASAP to provide the beneficiary with accurate information; therefore, please ask your Admissions Dept. to replace these by going to the website listed on the slide to use the new ones. The website also gives instructions on using the Important Message from Medicare. Blue Advantage: You may have seen a large increase in these kinds of patients as of July 1, 2005.

4. PRE-ADMISSION ADMISSION CONTINUED STAY ATTENDING PHYSICIAN CONCURS QIO CONCURS SWING BED HINNs TYPES OF HINNs In just a minute, we�ll discuss 4 different types of HINNs. I�ll give you an overview and practical information you can use. The types of HINNs include Pre-admission, Admission, Continued Stay--there are two situations we�ll talk about with these, and Swing Bed HINNs. We will also talk about NODMARs for the beneficiaries who have a Medicare HMO. Find out who the UR/Case Management people are so you will know who your audience is. Omit Swing Bed HINNs if they don�t have them.In just a minute, we�ll discuss 4 different types of HINNs. I�ll give you an overview and practical information you can use. The types of HINNs include Pre-admission, Admission, Continued Stay--there are two situations we�ll talk about with these, and Swing Bed HINNs. We will also talk about NODMARs for the beneficiaries who have a Medicare HMO. Find out who the UR/Case Management people are so you will know who your audience is. Omit Swing Bed HINNs if they don�t have them.

5. APPROPRIATE USE OF MEDICARE FUNDS PROVIDE APPROPRIATE HEALTH CARE SETTING FOR THE BENEFICIARY�S LEVEL OF CARE PURPOSE OF HINNs/NODMARs As you will notice, this session is entitled Keys to Success in Issuing HINNs, �Unlocking Opportunities�. What opportunities? Well, you have a great opportunity to ensure that Medicare funds are used appropriately. If an inpatient stay is medically unnecessary, this would be an inappropriate use of Medicare funds. A second opportunity is to make sure that the appropriate health care setting is used for the beneficiary�s level of care.As you will notice, this session is entitled Keys to Success in Issuing HINNs, �Unlocking Opportunities�. What opportunities? Well, you have a great opportunity to ensure that Medicare funds are used appropriately. If an inpatient stay is medically unnecessary, this would be an inappropriate use of Medicare funds. A second opportunity is to make sure that the appropriate health care setting is used for the beneficiary�s level of care.

6. CONSERVE MEDICARE DAYS FOR THE BENEFICIARY PROVIDE FACILITY THE ABILITY TO BILL FOR MEDICALLY UNNECESSARY DAYS. PURPOSE OF HINNs/NODMARs We also want to conserve Medicare days for the beneficiary. For example, the beneficiary has a 60-day benefit period where they pay a deductible (for days 1-60). Then, days 61-90, they pay a co-payment per day. Days 91-150 are considered lifetime reserve days. They never regain these days. If these or any other of the benefit days are wasted, such as inpt days billed to Medicare without medical necessity, this counts against the patient�s benefit days. Your facility will also have an opportunity to bill the beneficiary for medically unnecessary days, if the notice is given correctly. Unless you have gone through the proper steps to make the beneficiary liable, you can�t bill them. In other words, if you determine that the beneficiary doesn�t meet inpatient criteria, you should not bill Medicare. You also cannot bill the patient, unless they know that they are liable, after receiving a notice of non-coverage. Let�s clarify something very quickly about billing Medicare. You would show the entire time the patient was in the hospital; however, if there are some non-covered days, the bill should reflect �No bill or uncovered days.�We also want to conserve Medicare days for the beneficiary. For example, the beneficiary has a 60-day benefit period where they pay a deductible (for days 1-60). Then, days 61-90, they pay a co-payment per day. Days 91-150 are considered lifetime reserve days. They never regain these days. If these or any other of the benefit days are wasted, such as inpt days billed to Medicare without medical necessity, this counts against the patient�s benefit days. Your facility will also have an opportunity to bill the beneficiary for medically unnecessary days, if the notice is given correctly. Unless you have gone through the proper steps to make the beneficiary liable, you can�t bill them. In other words, if you determine that the beneficiary doesn�t meet inpatient criteria, you should not bill Medicare. You also cannot bill the patient, unless they know that they are liable, after receiving a notice of non-coverage. Let�s clarify something very quickly about billing Medicare. You would show the entire time the patient was in the hospital; however, if there are some non-covered days, the bill should reflect �No bill or uncovered days.�

7. REASONS FOR ISSUING DATE ISSUED DATE OF LIABILITY IMMEDIATE REVIEW RIGHTS RECONSIDERATION RIGHTS APPEAL RIGHTS CONTENT OF HINNs/NODMARs HINNs have to include the reasons for issuing, date issued, date of liability, immediate review rights, reconsideration rights and appeal rights (pages 2 & 3). This is for your protection. If anything is incorrect about the HINN, it is considered invalid. This means the beneficiary is not liable and you cannot bill him. Also, if AQAF performs a retrospective review of a HINN, and finds it invalid, you have to reimburse the beneficiary if any money has already been collected. You see how important it is. In your guidelines book, there are example letters to fit your situation. These are guides. Exhibits 1-9 must conform to the content but don�t have to be a duplicate. If you don�t use this wording exactly, be very careful to include all of the components we just discussed and also be careful to use the correct verbiage. Now, as I said, Exhibits 1-9 don�t have to be identical to the examples; however, Exhibit 10 is mandatory in the wording and cannot be altered by hospitals. Exhibit 10 tells the bene/rep that you have determined they no longer require an acute level of care but their doctor disagrees and you are asking for peer review by AQAF, also known as QIO Concurrence. Exhibit 10 has to be given before we get involved. Exhibit 10 is on page 23.HINNs have to include the reasons for issuing, date issued, date of liability, immediate review rights, reconsideration rights and appeal rights (pages 2 & 3). This is for your protection. If anything is incorrect about the HINN, it is considered invalid. This means the beneficiary is not liable and you cannot bill him. Also, if AQAF performs a retrospective review of a HINN, and finds it invalid, you have to reimburse the beneficiary if any money has already been collected. You see how important it is. In your guidelines book, there are example letters to fit your situation. These are guides. Exhibits 1-9 must conform to the content but don�t have to be a duplicate. If you don�t use this wording exactly, be very careful to include all of the components we just discussed and also be careful to use the correct verbiage. Now, as I said, Exhibits 1-9 don�t have to be identical to the examples; however, Exhibit 10 is mandatory in the wording and cannot be altered by hospitals. Exhibit 10 tells the bene/rep that you have determined they no longer require an acute level of care but their doctor disagrees and you are asking for peer review by AQAF, also known as QIO Concurrence. Exhibit 10 has to be given before we get involved. Exhibit 10 is on page 23.

8. Immediate review at the request of beneficiary or beneficiary representative Immediate review for QIO concurrence of continued stay HINN Reconsideration - Immediate or within 30 days Retrospective review QIO REVIEW OF HINNs The way we, as the QIO, get involved with the review of HINNs can be from a request by the benficiary or the rep; immediate review request by the hospital for QIO concurrence of a continued stay HINN, reconsideration or retrospective review. If the hospital requests our concurrence for a continued stay HINN, we have up to 2 working days to complete the review (this is after we have received the records). If the hospital requests us to review the record, remember that Exhibit 10 has to be issued to the bene/rep first. We will also need the information listed on the top portion of the QIO HINN/NODMAR Review Worksheet (revised from Hospital Request For QIO Concurrence of Continued Stay HINN Worksheet)---but the information that we need is the same. The way we, as the QIO, get involved with the review of HINNs can be from a request by the benficiary or the rep; immediate review request by the hospital for QIO concurrence of a continued stay HINN, reconsideration or retrospective review. If the hospital requests our concurrence for a continued stay HINN, we have up to 2 working days to complete the review (this is after we have received the records). If the hospital requests us to review the record, remember that Exhibit 10 has to be issued to the bene/rep first. We will also need the information listed on the top portion of the QIO HINN/NODMAR Review Worksheet (revised from Hospital Request For QIO Concurrence of Continued Stay HINN Worksheet)---but the information that we need is the same.

9. THE QIO HAS AUTHORITY TO DO ONLY IMMEDIATE REVIEWS OF NODMARs IMMEDIATE RECONSIDERATIONS AND APPEALS MUST BE DONE BY THE MEDICARE ADVANTAGE PLAN QIO REVIEW OF NODMARs Pages 49-51 Notice of Discharge and Medicare Appeal Rights� Regulations require that each Medicare Advantage (same as M+C) enrollee must receive a Notice of Non-Coverage before being released, once determined that inpatient hospital care is no longer necessary. If the enrollee or representative disagrees with the notice, they may only request an immediate QIO review, meaning they have to request us to review it no later than noon of the first working day, after the day the notice was given. If they miss that window, we can�t get involved. They would then have to request review by the HMO Ex: They receive a NODMAR on 5/24/05. They have to request he QIO to review it no later than noon on 5/25/05. **Don�t have to discuss if they don�t have these patients (Medicare Complete, Senior�s First or Viva). The QIO doesn�t routinely look at NODMARs otherwise. Whether you or the M+C organization issues the NODMAR depends on whether or not they have delegated that responsibility to you, as the hospital. Your UR/Case Management Dept. should have that information. That�s not something that we would know.Pages 49-51 Notice of Discharge and Medicare Appeal Rights� Regulations require that each Medicare Advantage (same as M+C) enrollee must receive a Notice of Non-Coverage before being released, once determined that inpatient hospital care is no longer necessary. If the enrollee or representative disagrees with the notice, they may only request an immediate QIO review, meaning they have to request us to review it no later than noon of the first working day, after the day the notice was given. If they miss that window, we can�t get involved. They would then have to request review by the HMO Ex: They receive a NODMAR on 5/24/05. They have to request he QIO to review it no later than noon on 5/25/05. **Don�t have to discuss if they don�t have these patients (Medicare Complete, Senior�s First or Viva). The QIO doesn�t routinely look at NODMARs otherwise. Whether you or the M+C organization issues the NODMAR depends on whether or not they have delegated that responsibility to you, as the hospital. Your UR/Case Management Dept. should have that information. That�s not something that we would know.

10. PREADMISSION HINN ADMISSION HINN CONTINUED STAY HINN NODMARs BENEFICIARY LIABILITY We will discuss liability issues for each of these type of reviews.We will discuss liability issues for each of these type of reviews.

11. PREADMISSION HINN Notice given before admission If admitted after they receive the notice, then liable at the time admitted BENEFICIARY LIABILITY The preadmission HINN is given just like it implies--before the patient is admitted. If you catch these beforehand and you can see that the plan is to admit but they won�t meet admission criteria, you can issue a preadmission HINN. If the patient is admitted after he receives the preadmission HINN, he is considered to have knowledge that services are not covered and is liable at the time he is admitted. Neither the Preadmission nor the Admission HINN requires the concurrence of the Attending MD or the QIO; however, as the UR reviewer or case manager, you should get your PA to agree with you before giving the notice. He/she makes that medical decision.Refer to Exhibit 1 on page 11. See footnote regarding Preadmission Notice.The preadmission HINN is given just like it implies--before the patient is admitted. If you catch these beforehand and you can see that the plan is to admit but they won�t meet admission criteria, you can issue a preadmission HINN. If the patient is admitted after he receives the preadmission HINN, he is considered to have knowledge that services are not covered and is liable at the time he is admitted. Neither the Preadmission nor the Admission HINN requires the concurrence of the Attending MD or the QIO; however, as the UR reviewer or case manager, you should get your PA to agree with you before giving the notice. He/she makes that medical decision.Refer to Exhibit 1 on page 11. See footnote regarding Preadmission Notice.

12. ADMISSION HINN Notice given day of admission before 3 PM, liable day of admission Notice given after 3 PM on day of admission or any day after day of admission, liable the day after notice is given BENEFICIARY LIABILITY For admission HINNs, there is only one scenario where the beneficiary can be liable the same day you issue the notice. Ex: Bene issued an admission HINN before 3pm on the same day he was admitted to the hospital, he is liable that day. Ex: He was admitted on Friday, 5/20/05. You reviewed the chart and saw that he didn�t meet admission criteria. You checked with your PA and he/she agreed that the patient didn�t meet. Remember that you don�t have to have the Attending�s or the QIO�s concurrence on admission HINNs. Anyway, you issue an admission HINN that day, 5/20/05, before 3pm. When is the patient liable? Answer: 5/20/05�the actual day of admission. For Admission HINNs, if you issue the notice after 3pm, the patient is liable the next day. The easiest way to understand this is if the patient gets the letter before 3pm the day they were admitted, they are liable the same day. But anytime or any day after that, they are liable the day after they receive the HINN. Ex: They came in on Friday, 5/20/05. You reviewed the chart late. They didn�t meet criteria and a notice was issued after 3pm. When are they liable? Answer: Saturday, 5/21/05. Another scenario: The patient came in Friday night. You don�t review the chart until Monday. They didn�t meet admission criteria (from Friday when they came in). You issue a notice on Monday morning. When are they liable? Answer: Tuesday 5/24/05 The bene is not liable until Tuesday. You cannot make them liable before then. The hospital cannot bill them for days before then. You also cannot bill Medicare for those medically unnecessary days. Just show them as �no bill� or uncovered days.For admission HINNs, there is only one scenario where the beneficiary can be liable the same day you issue the notice. Ex: Bene issued an admission HINN before 3pm on the same day he was admitted to the hospital, he is liable that day. Ex: He was admitted on Friday, 5/20/05. You reviewed the chart and saw that he didn�t meet admission criteria. You checked with your PA and he/she agreed that the patient didn�t meet. Remember that you don�t have to have the Attending�s or the QIO�s concurrence on admission HINNs. Anyway, you issue an admission HINN that day, 5/20/05, before 3pm. When is the patient liable? Answer: 5/20/05�the actual day of admission. For Admission HINNs, if you issue the notice after 3pm, the patient is liable the next day. The easiest way to understand this is if the patient gets the letter before 3pm the day they were admitted, they are liable the same day. But anytime or any day after that, they are liable the day after they receive the HINN. Ex: They came in on Friday, 5/20/05. You reviewed the chart late. They didn�t meet criteria and a notice was issued after 3pm. When are they liable? Answer: Saturday, 5/21/05. Another scenario: The patient came in Friday night. You don�t review the chart until Monday. They didn�t meet admission criteria (from Friday when they came in). You issue a notice on Monday morning. When are they liable? Answer: Tuesday 5/24/05 The bene is not liable until Tuesday. You cannot make them liable before then. The hospital cannot bill them for days before then. You also cannot bill Medicare for those medically unnecessary days. Just show them as �no bill� or uncovered days.

13. CONTINUED STAY HINN Admission must be medically necessary/approved first (if not, give admission notice rather than continued stay notice) Notice given when hospital determines continued stay is not medically necessary, is inappropriate, or is custodial in nature BENEFICIARY LIABILITY

14. CONTINUED STAY HINN Beneficiary is liable the third day, after notice is given (EX: Notice is given 8/8/05, liable 8/11/05) BENEFICIARY LIABILITY

15. NODMARs Enrollee liability, if no appeal requested Entitled to coverage until at least noon of the day after notice is provided Enrollee liability, if appeal requested Liable by noon the day after QIO notification (if determination upheld) BENEFICIARY LIABILITY According to the Code of Federal Regulations, 42 CFR 422.620, each MA enrollee must receive a Notice of Non-Coverage before being released from the hospital once it is determined that inpatient hospital care is no longer necessary. We realize that it is the MA Org. that initiates the notices and gives them, or either delegates you to give them; however, we wanted to inform you of the regulation regarding this. According to the Code of Federal Regulations, 42 CFR 422.620, each MA enrollee must receive a Notice of Non-Coverage before being released from the hospital once it is determined that inpatient hospital care is no longer necessary. We realize that it is the MA Org. that initiates the notices and gives them, or either delegates you to give them; however, we wanted to inform you of the regulation regarding this.

16. QIO Concurrence is required for Continued Stay HINNs when the Attending does not agree with plans to discharge the patient QIO CONCURRENCE

17. Process Hospital gives the beneficiary or representative, when applicable, notification that QIO concurrence is needed (Exhibit 10) Once Exhibit 10 is given, hospital calls AQAF to begin the process and sends requested information, including a copy of Exhibit 10 QIO CONCURRENCE

18. Process QIO completes review within 2 working days of either the request or receipt of any additional information requested QIO notifies hospital to issue the appropriate notice and also sends written notification of QIO concurrence QIO CONCURRENCE

19. SWING BEDS If Attending concurs: Beneficiary changes from acute to nursing facility/custodial level of care (Exhibit 3)�swing bed admission not medically necessary Beneficiary changes from acute to SNF level of care (primarily to notify that level of care is changing from acute to SNF level of care�Exhibit 4) SWING BEDS Exhibit 3, although indicating for Swing Bed Only, is when the beneficiary does not need hospital or skilled nursing care (notification prior to being admitted to hospital�s swing bed). Exhibit 6 is the same scenario above except the Attending does not concur that swing bed admission is not necessary, so this requires QIO concurrence first (after which Exhibit 6 is given).Exhibit 3, although indicating for Swing Bed Only, is when the beneficiary does not need hospital or skilled nursing care (notification prior to being admitted to hospital�s swing bed). Exhibit 6 is the same scenario above except the Attending does not concur that swing bed admission is not necessary, so this requires QIO concurrence first (after which Exhibit 6 is given).

20. SWING BEDS If Attending does not concur & QIO concurs: Beneficiary changes from acute to nursing facility/custodial level of care (Exhibit 6)�swing bed admission not medically necessary Beneficiary changes from acute to SNF level of care (primarily to notify that level of care is changing�Exhibit 7) SWING BEDS Exhibit 3, although indicating for Swing Bed Only, is when the beneficiary does not need hospital or skilled nursing care (notification prior to being admitted to hospital�s swing bed). Exhibit 6 is the same scenario above except the Attending does not concur that swing bed admission is not necessary, so this requires QIO concurrence first (after which Exhibit 6 is given).Exhibit 3, although indicating for Swing Bed Only, is when the beneficiary does not need hospital or skilled nursing care (notification prior to being admitted to hospital�s swing bed). Exhibit 6 is the same scenario above except the Attending does not concur that swing bed admission is not necessary, so this requires QIO concurrence first (after which Exhibit 6 is given).

21. Exhibit 9 is notice to beneficiary who does not meet admission for swing bed admission and is coming from another facility to your swing bed NEW, NEW, NEW, as of July 1, 2005!!! Section 521 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA), amended section 1869 of the SSA to require significant changes to the Medicare appeals procedures SWING BEDS The difference between Exhibit 3, 6 and 9 is that Exhibit 9 is when the beneficiary does not meet admission criteria for swing bed but they are coming from another facility to your swing bed. The other exhibits are when they are already in your facility and potentially going to your own swing bed. Exhibit 8 is no longer to be used; instead use the new Generic notice, as indicated above.The difference between Exhibit 3, 6 and 9 is that Exhibit 9 is when the beneficiary does not meet admission criteria for swing bed but they are coming from another facility to your swing bed. The other exhibits are when they are already in your facility and potentially going to your own swing bed. Exhibit 8 is no longer to be used; instead use the new Generic notice, as indicated above.

22. Affects SNFs (SNF level of care); also, CORFs, Hospices and HHAs Replacement of Exhibit 8 � beneficiary changes from SNF level of care (in swing bed) to nursing facility/custodial care SWING BEDS The difference between Exhibit 3, 6 and 9 is that Exhibit 9 is when the beneficiary does not meet admission criteria for swing bed but they are coming from another facility to your swing bed. The other exhibits are when they are already in your facility and potentially going to your own swing bed. Exhibit 8 is no longer to be used; instead use the new Generic notice, as indicated above.The difference between Exhibit 3, 6 and 9 is that Exhibit 9 is when the beneficiary does not meet admission criteria for swing bed but they are coming from another facility to your swing bed. The other exhibits are when they are already in your facility and potentially going to your own swing bed. Exhibit 8 is no longer to be used; instead use the new Generic notice, as indicated above.

23. New Notice of Medicare Provider Non-Coverage (Generic Notice), to be given to all Medicare beneficiaries, in SNF level of care, at least two days before the proposed end of services (effective date), or if services are fewer than two days in duration, the notice should be issued at the time of admission SWING BEDS This began July 1, 2005. If beneficiary misses the timeframe for expedited appeal, the QIO will still conduct a non-expedited appeal review (within 7 days if they are still in the facility/receiving services or within 30 days if they are no longer receiving services). They must appeal at the latest within 60 days of the effective date for non-expedited appeal.This began July 1, 2005. If beneficiary misses the timeframe for expedited appeal, the QIO will still conduct a non-expedited appeal review (within 7 days if they are still in the facility/receiving services or within 30 days if they are no longer receiving services). They must appeal at the latest within 60 days of the effective date for non-expedited appeal.

24. Beneficiary must request a QIO expedited appeal by noon of day prior to termination of services. Provider must then issue the Detailed Notice, as requested by the QIO Notices found at www.cms.hhs.gov/medicare/bni See sample notices in packet SWING BEDS This began July 1, 2005. If beneficiary misses the timeframe for expedited appeal, the QIO will still conduct a non-expedited appeal review (within 7 days if they are still in the facility/receiving services or within 30 days if they are no longer receiving services). They must appeal at the latest within 60 days of the effective date for non-expedited appeal.This began July 1, 2005. If beneficiary misses the timeframe for expedited appeal, the QIO will still conduct a non-expedited appeal review (within 7 days if they are still in the facility/receiving services or within 30 days if they are no longer receiving services). They must appeal at the latest within 60 days of the effective date for non-expedited appeal.

25. Insert AQAF�s appeal # on the Generic notice (1-800-366-1486) Provider must supply all information, as requested by the QIO, including a copy of the Generic and Detailed notices, not later than by close of business of the day the QIO notifies provider of the appeal (7 days/week) QIO must make a determination within 72 hours from receipt of an expedited appeal request. More information is found at www.aqaf.com SWING BEDS

26. HINNs are monitored by the QIO for: Appropriate process Accurate and appropriate content Validity of decision to issue the notice Correct liability dates QIO MONITORING OF HINNs HINNs are monitored by the QIO for the appropriate process. We also look at them for accurate and appropriate content. For example, we see if the verbiage is correct. Also, if the liability dates are correct, etc. One thing that we see sometimes is a HINN that is dated incorrectly or after the bene has already left the hospital. The liability dates sometimes incorrectly shows the bene liable days prior to receiving the notice. If anything is incorrect, it makes the HINN invalid. Therefore, if you haven�t billed the bene yet, you can�t! And, if you have received any monies from the bene, you have to pay it back. We also look at the validity of the decision to issue the notice. Did they really meet criteria and you said they didn�t? Sometimes we find that hospitals issued a contined stay notice but in reviewing the chart, we find that they didn�t even meet admission criteria! And, we already talked about correct liability dates.HINNs are monitored by the QIO for the appropriate process. We also look at them for accurate and appropriate content. For example, we see if the verbiage is correct. Also, if the liability dates are correct, etc. One thing that we see sometimes is a HINN that is dated incorrectly or after the bene has already left the hospital. The liability dates sometimes incorrectly shows the bene liable days prior to receiving the notice. If anything is incorrect, it makes the HINN invalid. Therefore, if you haven�t billed the bene yet, you can�t! And, if you have received any monies from the bene, you have to pay it back. We also look at the validity of the decision to issue the notice. Did they really meet criteria and you said they didn�t? Sometimes we find that hospitals issued a contined stay notice but in reviewing the chart, we find that they didn�t even meet admission criteria! And, we already talked about correct liability dates.

27. IDENTIFY CASES WHERE A HINN WAS ISSUED BY: SUBMITTED COPIES OF ISSUED HINNs MONTHLY LOGS PROCESSED CLAIMS DATA QIO MONITORING OF HINNs We identify cases where a HINN was issued by submitted copies of issued HINNs. You should send a copy of the HINNs that you issued to us (QIO), within 3 working days of the issuance. These should be sent to AQAF to Review Dept.�s attention. You should also keep a monthly log of HINNs issued and send this to AQAF to the Review Dept. (page 60). Even if you don�t give any notices, turn in a monthly log and just notate that none were given. Processed claims data also provide us with information. These are retrospective. Cases are selected by CMS monthly (they select the ones that, based on our review of your HINNs that are turned in, show a liability for the bene and the ones that are incorrect/invalid).We identify cases where a HINN was issued by submitted copies of issued HINNs. You should send a copy of the HINNs that you issued to us (QIO), within 3 working days of the issuance. These should be sent to AQAF to Review Dept.�s attention. You should also keep a monthly log of HINNs issued and send this to AQAF to the Review Dept. (page 60). Even if you don�t give any notices, turn in a monthly log and just notate that none were given. Processed claims data also provide us with information. These are retrospective. Cases are selected by CMS monthly (they select the ones that, based on our review of your HINNs that are turned in, show a liability for the bene and the ones that are incorrect/invalid).

28. COMMONLY ASKED QUESTIONS HINNs Now, we will go over some commonly asked questions (pages 55-58). It would be impossible to cover every scenario, but these questions should provide some general guidelines.Now, we will go over some commonly asked questions (pages 55-58). It would be impossible to cover every scenario, but these questions should provide some general guidelines.

29. To Whom Can You Issue a HINN? Beneficiary Beneficiary Representative Family Member Friend Guardian Someone that can act on behalf of the beneficiary to ask for an Immediate Review COMMONLY ASKED QUESTIONS To Whom Can you issue a HINN? (page 57) You can issue a HINN to the beneficiary only if they are capable of taking care of their needs. For example, can they handle their own checkbook, bills, etc? If the beneficiary is not competent, you can give the HINN to a beneficiary rep. It can be a family member, friend, guardian--anyone who can act on behalf of the beneficiary to ask for an immediate review. This does not mean they are responsible for the bill. To Whom Can you issue a HINN? (page 57) You can issue a HINN to the beneficiary only if they are capable of taking care of their needs. For example, can they handle their own checkbook, bills, etc? If the beneficiary is not competent, you can give the HINN to a beneficiary rep. It can be a family member, friend, guardian--anyone who can act on behalf of the beneficiary to ask for an immediate review. This does not mean they are responsible for the bill.

30. When should you give a HINN to someone other than the beneficiary? If the beneficiary is incapable of managing his/her own affairs or is incompetent. COMMONLY ASKED QUESTIONS When should you give a HINN to someone other than the beneficiary? (page 56, question 5 and page 57, question 10) We just discussed that. If the beneficiary is incapable of managing his/her own affairs or is incompetent. You are responsible for determining whether the beneficiary, upon admission, is mentally competent and capable of transacting business (as opposed to being incapable of handling his/her own affairs, unable to sign and negotiate checks). When should you give a HINN to someone other than the beneficiary? (page 56, question 5 and page 57, question 10) We just discussed that. If the beneficiary is incapable of managing his/her own affairs or is incompetent. You are responsible for determining whether the beneficiary, upon admission, is mentally competent and capable of transacting business (as opposed to being incapable of handling his/her own affairs, unable to sign and negotiate checks).

31. If No One is Available to Receive the HINN, How Can You Give It? By telephone followed up by mailing HINN By Return Receipt Certified mail COMMONLY ASKED QUESTIONS If no one is available to receive the HINN, how can you give it? (page 3) By telephone followed up by mailing the HINN. Have a witness present when you make the call. The date of the phone conversation is the date of receipt of the notice. Document this on the HINN. When you can�t contact the bene rep by phone, send it certified mail, return receipt requested. The date that someone at the representative�s address signs (or refuses to sign) the receipt, is considered the date of receipt of the notice. If the notice is returned to the hospital, with no indication of a refusal date, the liability is considered to be the second working day after the hospital�s mailing date (postmarked by the postal station). If no one is available to receive the HINN, how can you give it? (page 3) By telephone followed up by mailing the HINN. Have a witness present when you make the call. The date of the phone conversation is the date of receipt of the notice. Document this on the HINN. When you can�t contact the bene rep by phone, send it certified mail, return receipt requested. The date that someone at the representative�s address signs (or refuses to sign) the receipt, is considered the date of receipt of the notice. If the notice is returned to the hospital, with no indication of a refusal date, the liability is considered to be the second working day after the hospital�s mailing date (postmarked by the postal station).

32. If a Beneficiary Refuses a Nursing Home Bed, can a HINN Be Issued? Yes, if the patient is requiring skilled care at a SNF, as long as the attending physician or QIO concurs, unless the SNF bed is a true inconvenience for the family/caregivers. You may give a HINN to a patient who refuses a nursing home bed that does not require SNF level of care as long as the patient is meeting discharge indicators and the attending physician or QIO concurs. COMMONLY ASKED QUESTIONS If a beneficiary refuses a nursing home bed, can a HINN be issued? (page 55) Let�s clarify nursing home beds. There are skilled beds and custodial (non-skilled) beds. If the patient requires skilled care at a SNF and they refuse that bed, you can give a HINN--as long as the Attending MD concurs or QIO concurs, unless the SNF bed is a true inconvenience for the family/caregivers. Also, remember that you have to have a SNF bed available on the day you issue the HINN. Let�s talk about the SNF bed being an inconvenience. Some people think if the SNF is within a 60-mile radius (or some other specific mileage), the patient has to accept that bed; however, that�s not true. There�s no specific mileage range. You, as the case manager, will have to assess the situation and determine if it�s a true inconvenience for the family. An example of this is where two elderly ladies were the primary caregivers of their aunt. The aunt was to be placed in a SNF 25 miles away. Now this may not appear to be an inconvenience but for them it was. Their only means of transportation was the bus. The bus did not go to the location of the SNF, so they wouldn�t be able to visit their aunt. As the primary caregivers, this would be an inconvenience to them. You may give a HINN to a patient who refuses a nursing home bed that does not require SNF level of care (requires custodial care), as long as the patient is meeting discharge indicators and the AP or QIO concurs.If a beneficiary refuses a nursing home bed, can a HINN be issued? (page 55) Let�s clarify nursing home beds. There are skilled beds and custodial (non-skilled) beds. If the patient requires skilled care at a SNF and they refuse that bed, you can give a HINN--as long as the Attending MD concurs or QIO concurs, unless the SNF bed is a true inconvenience for the family/caregivers. Also, remember that you have to have a SNF bed available on the day you issue the HINN. Let�s talk about the SNF bed being an inconvenience. Some people think if the SNF is within a 60-mile radius (or some other specific mileage), the patient has to accept that bed; however, that�s not true. There�s no specific mileage range. You, as the case manager, will have to assess the situation and determine if it�s a true inconvenience for the family. An example of this is where two elderly ladies were the primary caregivers of their aunt. The aunt was to be placed in a SNF 25 miles away. Now this may not appear to be an inconvenience but for them it was. Their only means of transportation was the bus. The bus did not go to the location of the SNF, so they wouldn�t be able to visit their aunt. As the primary caregivers, this would be an inconvenience to them. You may give a HINN to a patient who refuses a nursing home bed that does not require SNF level of care (requires custodial care), as long as the patient is meeting discharge indicators and the AP or QIO concurs.

33. If a patient is admitted for nursing home placement, can you give a Pre-admission or Admission HINN? A HINN would be appropriate if the patient does not meet admission criteria. COMMONLY ASKED QUESTIONS If a patient is admitted for nursing home placement, can you give a Preadmission or Admission HINN? Sometimes you have patients where the doctor says, �Admitting for nursing home placement.� This is a red flag. If they don�t meet admission criteria, it would be appropriate to issue a HINN. The preadmission HINN would be appropriate if you catch it prior to the patient�s admission to the hospital.If a patient is admitted for nursing home placement, can you give a Preadmission or Admission HINN? Sometimes you have patients where the doctor says, �Admitting for nursing home placement.� This is a red flag. If they don�t meet admission criteria, it would be appropriate to issue a HINN. The preadmission HINN would be appropriate if you catch it prior to the patient�s admission to the hospital.

34. If you need to get QIO Concurrence to issue a Continued Stay HINN, when should you call AQAF? AQAF requests that you call before 3:00PM on the day you wish to give the HINN. If you do not call by 3:00PM or earlier we may not be able to give you a determination until the following working day. COMMONLY ASKED QUESTIONS If you need to get QIO Concurrence to issue a continued stay HINN, when should you call AQAF? You need to call as early as possible to get things going. There are several steps involved. We have to contact the ben/rep to get their opinion on the matter. We also need the entire chart from you. It is best to send it overnight to us. With it include exhibit 10. We have up to 2 working days--after we receive the medical record--to complete the review. If we get things early enough, however, we try to get it completed before that. An AQAF Physician will review the chart and attempt to contact the UR Physician, if necessary and the Attending. After he makes his determination, we contact the case manager and the bene/rep by phone and follow-up with a letter. We will let you know, when we phone, whether we agree that it is appropriate to issue a HINN or not. If you need to get QIO Concurrence to issue a continued stay HINN, when should you call AQAF? You need to call as early as possible to get things going. There are several steps involved. We have to contact the ben/rep to get their opinion on the matter. We also need the entire chart from you. It is best to send it overnight to us. With it include exhibit 10. We have up to 2 working days--after we receive the medical record--to complete the review. If we get things early enough, however, we try to get it completed before that. An AQAF Physician will review the chart and attempt to contact the UR Physician, if necessary and the Attending. After he makes his determination, we contact the case manager and the bene/rep by phone and follow-up with a letter. We will let you know, when we phone, whether we agree that it is appropriate to issue a HINN or not.

35. If you need to get QIO Concurrence to issue a Continued Stay HINN, do you have to let the patient know you are thinking about giving a HINN? Yes. You must give the patient or the patient�s representative Exhibit 10. This is a mandatory requirement. This gives the patient/representative notice that the QIO will be contacting them for their input about the discharge. COMMONLY ASKED QUESTIONS If you need to get QIO Concurrence to issue a continued stay HINN, do you have to let the patient know you are thinking about giving a HINN? Yes, we already talked about that. You must give the patient, or the patient�s rep Exhibit 10. This is a mandatory requirement. This notice cannot be altered by hospitals. Exhibit 10 gives the patient/rep notice that the QIO will be contacting them for their input about the discharge. If you need to get QIO Concurrence to issue a continued stay HINN, do you have to let the patient know you are thinking about giving a HINN? Yes, we already talked about that. You must give the patient, or the patient�s rep Exhibit 10. This is a mandatory requirement. This notice cannot be altered by hospitals. Exhibit 10 gives the patient/rep notice that the QIO will be contacting them for their input about the discharge.

36. EXAMPLES THE GOOD THE BAD THE UGLY (picture not found) Let�s look at some examples. We have some that are correct and some that are incorrect, and therefore invalid (which means you can�t bill the patient or Medicare). The examples are in your packets.Let�s look at some examples. We have some that are correct and some that are incorrect, and therefore invalid (which means you can�t bill the patient or Medicare). The examples are in your packets.

37. Call AQAF (205)970-1600 or (800)760-4550 Pam Taylor, ext. 3512 Cathy Dixon, ext. 3426 Laura Rutledge, ext. 3429 Barbara Baites, ext. 3228 Joan Wilder, ext. 3218 Anita Meyers, ext. 3217 Cynthia McIntosh, ext. 3506 We cannot tell you to give a HINN but we can explain the process. HINN Help is Available You can call if there are questions. Remember that we can�t tell you whether to give the HINN or not--just by information over the phone. We won�t have the entire chart, you will. We can assist with the guidelines and explain the process. You can call if there are questions. Remember that we can�t tell you whether to give the HINN or not--just by information over the phone. We won�t have the entire chart, you will. We can assist with the guidelines and explain the process.

38. Alabama Quality Assurance Foundation This material was prepared by Alabama Quality Assurance Foundation (AQAF), the Medicare Quality Improvement Organization for Alabama under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-AL-BENE -05-01.