Expedited Review Process

1. Expedited Review Process Mountain-Pacific Quality Health April 2010

2. Benefits Improvement and Protection Act (BIPA) §521 Federal Register, Friday, November 26, 2004 • 42 CFR 405.1200-1206 • Amended section 1869 of the Social Security Act • Requires a process in which the beneficiary may obtain an expedited determination in response to the termination of provider services

3. Expedited Determinations – Grijalva and BIPA • FFS Medicare Beneficiaries • Medicare Advantage Beneficiaries • HHAs, SNFs (includes Swing Beds, ECFs TCUs), CORFs and Hospices (FFS only) • Given When Coverage of Medicare Services Ends

4. Expedited Determinations • 2-step Notice Process (Separate forms for FFS and Medicare Advantage) • 1st Notice (Notice of Medicare Provider Non-Coverage: Generic Notice) • 2nd Notice (Detailed Explanation of Non-Coverage: Detailed Notice) • Only given if beneficiary appeals to QIO

5. Provider Responsibility Medicare Beneficiary’s Rights Before complete termination of services, the provider must deliver a valid written notice to the beneficiary of the decision to terminate services.

6. Generic Notice • Appropriate for… • Discharge from a residential provider • Complete cessation of coverage at the end of a course of treatment • Not appropriate for… • Exhaustion of benefits • Reduction in services • Hospital transfer • Refusal of care • Notices available online • www.cms.gov/bni

7. Expedited Determinations • Beneficiary contact (written/phone) QIO by: • noon the day before Effective Date on Notice • QIO must contact provider “immediately” • Provider must get Detailed Notice to Bene and Mountain-Pacific by COB same day • 72 hours to render a decision, must be available on weekends to receive peer’s decision and give decision to facility and beneficiary.

8. Provider Responsibility • Assign a designated person and at least one back-up person to respond to QIO’s requests for patient notices and medical records • Staff instructions • Appeals process • Accessing the medical records • Material to be faxed to QIO • Actions based on QIO’s determination

9. Provider Responsibility • Provide QIO instructions for handling appeal requests • Designated persons to contact in case of an appeal review • Level of urgency • Educate all staff on appeals • The BIPA and Grijalva appeals process • Roles and responsibilities within your organization

10. Provider Responsibility Content of Generic Notice • Beneficiary’s Name and HIC number • Date Coverage of Service ends • Type of coverage ending • Name and telephone number for Mountain-Pacific 1-800-497-8232 • Date beneficiary’s financial liability begins is the day after coverage ends • Description of right to appeal • Description of right to detailed information • Any other information required by CMS

11. Provider Responsibility Valid Notice • Appropriate timing of delivery • Correct content of notice • Beneficiary signed and dated notice • POA receives appeal information on date notice is given

12. Perfect Notice absolutely • Correct form withno changes All the right parts • Displays OMB Approval number in the upper right corner • Describes the appeal process, including how to contact Mountain-Pacific • Includes the CMS form number, expiration date, and the CMS language at the bottom of page 2

13. Notice Delivery Beneficiary Refuses to Sign • Annotate the notice to indicate the refusal. • The date of the refusal is the date of receipt of the notice.

14. Avoiding Invalid Generic Notice • Deliver the Generic Notice at least two days PRIOR to the date of termination of services. • Explain appeals process to the beneficiary or representative. • If the beneficiary is impaired, and the representative is not available, mail the Generic Notice to the patient’s designated representative. • If MP determines the beneficiary did not receive a valid notice, the provider may be liable for continued services until two calendar days after the beneficiary receives a valid notice.

15. Medicare Beneficiary Appeal Request The beneficiary (or representative) must call Mountain-Pacific and request an expedited appeal by noon of the next day after receiving the Generic Notice,

16. Medicare Beneficiary Untimely Appeal If a valid notice was issued, a non-expedited review is performed • If services are continuing, a decision in 7 days • If no longer receiving services, a decision in 30 days

17. Responsibility of QIO Determination Notify the beneficiary (or representative), beneficiary’s physician, and the health care provider. • Initial notification may be made by telephone. • A written notification must follow.

18. Responsibility of QIO Written Notification • Rationale for determination • Explanation of the Medicare payment consequences and the date the beneficiary becomes liable for services • Information about reconsideration rights, including how to request appeal and the time period

19. Detailed Notice • Provide the beneficiary a description of any applicable Medicare coverage rules, instruction, or other Medicare policy rules or information about obtaining a copy of the Medicare policy • Facts specific to the beneficiary and relevant to the coverage determination to advise the beneficiary of the applicability of the coverage rule or policy to the beneficiary’s case • Any other information required by CMS • Specific and detailed explanation why services are either no longer reasonable and necessary or no longer covered • No Beneficiary signature requirement

20. Medical record contents • Hospital discharge summary • SNF admission H&P and nursing admission assessment • Skilled therapy (PT, OT, Speech) admission assessment • Weekly skilled therapy summary reports • Skilled therapy discharge summary (if applicable)

21. Medical record contents (continued) • Progress notes (MD, RN, PT/OT, Speech, Case Management/Social Service) • Detailed Notice of Non-coverage • Physician’s order & medication administration records • Lab & x-ray results • Consultation reports

22. Medicare Beneficiary Reconsideration Request • Beneficiary may request a reconsideration of appeal • Only the beneficiary (or representative) may ask for a reconsideration • Conducted by Qualified Independent Contractors (QIC) • Prepare cases for Administrative Law Judge (ALJ) review, if appropriate

23. Expedited Reconsideration • QIC must notify MP on day request received • MP has 2 hours to provide record to QIC • QIC has 72 Hours from: • receipt of request for recon and • receipt of medical or other records • Maximus Federal Services, Inc.

24. Financial Liability • Medicare coverage continues until the date and time designated on the valid Generic Notice, unless MP or QIC reverses the provider’s service termination decision. • If MP’s decision is delayed because provider did not supply necessary timely information or records, provider may be liable for costs of any additional coverage.

25. Financial Liability • If MP determines beneficiary did not receive a valid notice, provider may be liable for continued services until two days after the beneficiary receives valid notice. • If MP upholds the notice, beneficiary is financially liable for services received after the effective date.

26. Financial Liability • If MP overturns the notice, Medicare will continue to cover services. • Providers are not to bill beneficiary for any disputed services until the expedited determination process (and reconsideration process, if applicable) is completed.

27. Mountain-Pacific Medicare Appeals Contacts Chris Tabbert, RN, 1-800-497-8232, ext. 5881, ctabbert@mtqio.sdps.org Rhonda Finstad, RHIA, CCS, 1-800-497-8232, ext. 5892, rfinstad@mtqio.sdsp.org Marcy Gallagher, RHIA, CPHQ, 800-497-8232, ext. 5858, mgallagher@mtqio.sdps.org