Notices of Medicare Non-Coverage: Getting it Right the First Time

2. Notices of Medicare Non-Coverage: Getting it Right the First Time Kristin Lueschow, RN, RRT, WCC, BAHA Nurse Consultant MetaStar, Inc. Jenny White, RN Medicare Lead/Nurse Consultant MetaStar, Inc.

3. Objectives • Identify the correct CMS required notices • Review the timing and delivery requirements of CMS notices • Review the expedited process and provider responsibilities • Review the CMS website resources

4. Who is MetaStar? • An independent, not-for-profit organization • Mission: to effect positive change in the quality, efficiency and effectiveness of health care • Contract with Centers for Medicare and Medicaid Services (CMS) as the Medicare Quality Improvement Organization (QIO) for Wisconsin

5. Medicare Coverage • Beneficiary’s Medicare coverage may be: • Original Medicare Coverage • Fee-for-service (FFS) • Notice of Medicare Provider Non-Coverage (NOMPNC) • Medicare Advantage Plan • Notice of Medicare Non-Coverage (NOMNC)

6. Medicare Advantage Notice of Non-coverage History • Grijalva v. Shalala: 1993 class action lawsuit brought by beneficiaries enrolled in the Medicare risk-based managed care organization program • Challenged the adequacy of the managed care appeals process

7. Medicare Advantage Notice of Non-coverage History (Cont.) • Settlement agreement approved by the Arizona District Court on December 4, 2000 • Under the settlement agreement, the Centers for Medicare & Medicaid Services (CMS) agreed to publish a notice of proposed rulemaking proposing regulations that would establish new notices and appeals procedures when a MA organization decides to terminate coverage or provide services to an enrollee

8. Medicare Advantage Notice of Non-coverage History (Cont.) • Key element to agreement was that CMS would propose to establish an independent review entity to conduct fast-track reviews of appeals of decisions to terminate services

9. Medicare Advantage Notice History • CMS determined QIOs would conduct these reviews because they had the necessary health care reviewers to make the medical necessity decisions • QIOs have extensive experience with this type of review process

10. Medicare Advantage Notice History (Cont.) • Medicare Advantage enrollees receive a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare-covered • skilled nursing facility (SNF) • home health (HH) • comprehensive outpatient rehabilitation facility (CORF) services   • The NOMNC informs individuals of their right to an immediate, independent review of the proposed discontinuation of services 

11. Medicare Advantage Enrollees Rights • MA enrollees have the right to request a QIO fast-track review to appeal the MA organization’s decision to terminate coverage of Medicare covered services

12. FFS Notice of Non-coverage History • Original, fee for service Medicare beneficiaries were given the same appeal rights • the Benefits Improvement and Protection Act (BIPA) §521 was passed November 2004

13. FFS Notice of Non-coverage History • As of July 1, 2005, • Home Health Agencies (HHAs) • Skilled Nursing Facilities (SNFs) • Comprehensive Outpatient Rehabilitation Facilities (CORFs) • Hospice providers • are required to notify beneficiaries of their right to a new expedited review process when these providers anticipate that Medicare coverage of their services will end

14. Identifying the Correct Notice to Issue • The provider must determine which Notice of Non-coverage to issue based on the beneficiary’s Medicare coverage: • FFS: Notice of Medicare Provider Non-coverage (NOMPNC) • MA: Notice of Medicare Non-coverage (NOMNC)

15. Fee for ServiceNotice of Medicare Provider Non-coverage • OMB Approval number 0938-0953 • Form number CMS-10123 • Expiration date 07/31/2011 • Also called a generic notice

16. Medicare AdvantageNotice of Medicare Non-coverage • OMB approval number 0938-0910 • Form No. CMS-10095 • Expiration Date 08/31/2010 • Also called an Advance Notice

17. When to Issue a Notice of Non-coverage • When all covered Medicare Part A services are ending • When all Medicare Part B services are ending

18. When a Notice of Non-coverageShould NOT be Issued • When the beneficiary has exhausted Medicare benefit days • When the beneficiary is transferring to a higher level of care (hospital) • When the beneficiary is transferring to another SNF • When the beneficiary decides to leave

19. Issuing a Valid Notice • Must use the appropriate CMS approved, standardized form • Providers may not deviate from the content of the form except where indicated • Minimum 12 point font • The name, address, and telephone number of plan or provider that actually delivers the notice required at top of the notice • Enrollee’s name • Patient ID number (no protected health information)

20. Issuing a Valid Notice (Cont.) • Must be issued at least two days prior to the effective date • Type of service ending must be entered • i.e., skilled nursing services or Medicare Part B services • Valid delivery to beneficiary or representative

21. Valid Delivery • The beneficiary must be able to understand the purpose and contents of the notice in order to sign for receipt of it • If the beneficiary is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative • If refuses to sign, document refusal on the notice with date, time and staff signature

22. Valid Delivery (Cont.) • Telephone notification must include • Effective date and financial liability • Appeal rights and MetaStar’s telephone number • Deadline for the appeal • Confirm conversation by mailing written notice • Document on the notice date and time of verbal notification, appeal rights explained, and MetaStar’s telephone number was provided

23. Valid Delivery (Cont.) • Unable to make phone contact • Mail notice to representative by certified mail, return receipt requested • Date someone signs at address (or refuses to sign) is date of receipt • If the notice is returned by the post office with no indication of refusal date, the beneficiary liability starts on the second working day after the providers mailing date

24. CMS Website • Beneficiary Notices Initiative (BNI) • www.cms.hhs.gov/bni • FFS ED notices and instructions • MA ED notices and instructions • FFS questions and answers

27. MetaStar’s Availability for Appeals • Accepts patient requests for notice of non-coverage appeals 24 hours/day • Performs appeal reviews 7 days/week during normal business hours • Voice mail after hours • Health Insight on weekends

28. Appeal Process • Beneficiary or representative must call MetaStar by noon the day before the effective date • FFS appeal requests received after noon will be processed but considered untimely • MA appeal requests received after noon will be referred to the MA plan

29. Appeal Process:MetaStar’s Responsibilities • Obtain comments from the beneficiary or representative, provider, MA plan (if applicable) and physician (if FFS) • Provider must fax the Generic/Advance notice immediately • MetaStar will validate the notice • If valid, MetaStar will request the medical record from the provider • If invalid, MetaStar will notify the provider with instructions on how to proceed

30. What makes a notice invalid? • Requirements of timing were not followed • Lack of OMB approval number • Notice was not issued to an appropriate representative • Method of delivery was incorrect ( i.e., left a voicemail without mailing) • Provider did not retain a copy of the notice; however, if the beneficiary /representative can produce the notice, MetaStar will proceed with the process

31. What makes a notice invalid? (Cont.) • CMS approved form is not used (i.e., a FFS beneficiary receives an MA notice) • Parts of the language of the notice are missing • Notice is not signed and there is no reference to delivery • Incorrect or missing expiration date

32. Invalid Notice Process • If the notice is determined to be invalid, a new notice must be reissued • MA: reissue new notice with new effective date • FFS: reissue new notice with same effective date and asterisk • See the www.cms.hhs.gov/bni, Revised Expedited Determination Q&A’s as of March 2006, page 26, question 13

34. Appeal Process:Provider’s Responsibilities • Issue a Detailed Explanation of Non-coverage (DENC) to the beneficiary/representative • Provide beneficiary specific comments • Fax the DENC and the medical record to MetaStar within the required timeframes (usually within 24 hours) • Must have non-business day process and contacts established

35. Detailed Explanation of Non-coverage (DENC) • Provider must issue a DENC to beneficiary/representative no later than close of business day of MetaStar’s notification of an appeal request • Standardized CMS notice must be used • FFS: Form number CMS-10124 • MA: Form number CMS-10095 • The name, address, and telephone number of plan or provider that actually delivers the notice required at top of the notice • MA plans often complete their own and fax to the QIO

36. Detailed Explanation of Non-coverage (Cont.) • Must include: • the date it is issued • Beneficiary’s name • Patient ID number (no PHI) • Type of Medicare covered service • Beneficiary specific facts used to make the decision

37. Expedited Determination Timelines • MetaStar will make a determination • FFS appeal: within 72 hours of a timely request • MA: 24 hours of receiving the medical record • Beneficiary/beneficiary representative, provider, physician and MA plan, if applicable, will be notified by phone, followed by a written notice

38. Beneficiary Financial Liability • If MetaStar agrees with the Notice of Non-coverage, the beneficiary is liable for costs starting the day after the effective date • If MetaStar disagrees with the Notice of Non-coverage • Medicare covered services continue • The beneficiary is not liable for continued services (except for coinsurance and deductibles)

39. Reconsiderations • Beneficiary/representative has the right to a second review when MetaStar agrees with the Notice of Non-coverage • Same medical record documentation is used

40. FFS Reconsiderations • Maximus, a Qualified Independent Contractor (QIC), performs the review • Beneficiary/representative must call the QIC by noon the next day following verbal notification

41. MA Reconsiderations • MetaStar performs the MA reconsiderations • Beneficiary/representative must contact MetaStar by telephone or in writing no later than 60 calendar days from the date of MetaStar’s determination letter • Different physician reviewer • Reconsiderations are completed within 14 days. • Beneficiary/beneficiary representative, provider, and MA plan are notified of determination by phone, followed by a written notice

42. Reconsideration Beneficiary Financial Liability • If MetaStar or the QIC upholds the original determination, the beneficiary is liable for costs starting the day after the effective date • If MetaStar or the QIC overturn the original determination, the beneficiary is not liable for further services (except for coinsurance and deductibles)

43. Questions?

44. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 Jenny White, RN, (608) 274-1940 or (800) 362-2320 Ext. 8261 Kristin Lueschow, RN, RRT, WCC, BAHA (608) 274-1940 or (800) 362-2320 Ext. 8295 www.metastar.com This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.  9SOW-WI-BENP-10-04.