1. MONITORING GRIJALVA 2005 Patricia Hokenson, RN, MSN, Region IX
Centers for Medicare & Medicaid Services
November 9, 2005

2. OBJECTIVES Review Grijalva Final Rule
Provide Results of CMS 2005 Grijalva Monitoring
Review CMS Grijalva Monitoring Worksheets
Identify Opportunities for Improvement

3. Review Grijalva Final Rule

4. GRIJALVA HISTORY 1993 Class action lawsuit
Challenged adequacy of notice and appeal rights
Final regulation published in April 2003
Implementation of provider notices January 2004

5. GRIJALVA REGULATION
New notification for termination of provider services (SNF, HHA and CORF) 42 CFR and
Expanded grievance process 42 CFR
Revised process for disputed termination of inpatient hospitalization 42 CFR

6. REQUIRED CMS NOTICES Notice of Medicare Non-Coverage (NOMNC)
Detail Explanation of Non-Coverage (DENC)

7. Provide Results of CMS 2005 Grijalva Monitoring

8. CMS MONITORING REVIEW
Review Period: January 1, 2005 to November 1, 2005
Review of 11 MAOs in Region IX

9. CMS MONITORING REVIEW GUIDE ELEMENTS
OP10: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Timeliness)
OP11: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Notice Content)

10. CMS MONITORING REVIEW GUIDE ELEMENTS
OP12: Detailed Explanation of Non-Coverage of Provider Services (Timeliness)
OP13: Detailed Explanation of Non-Coverage of Provider Services (Notice Content)
OP14: Effectuation of QIO Decision Reversals

11. OP10: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Timeliness)

12. OP11: Termination of Provider Services: Notice of Termination of SNF, HHA, or CORF Services (Notice)

13. OP12: Detailed Explanation of Non-Coverage of Provider Services (Timeliness)

14. OP13: Detailed Explanation of Non-Coverage of Provider Services (Notice)

15. OP14: Effectuation of QIO Decision Reversals

16. Review CMS Grijalva Monitoring Worksheets

17. CMS MONITORING REVIEW Work Sheets
OP4 Work Sheet: Evaluates elements OP10 and OP11
OP5 Work Sheet: Evaluates Op12, OP13 and OP14

18. Identify Opportunities for Improvements

19. Notice Issues Invalid NOMNCs Late DENCs
Integrity of Notices (NOMNCs and DENCs)

20. Chapter 13 Revisions 10/1/05 Valid Delivery of NOMNC Delivery of DENC
Authority of QIO To Request Enrollee Records

21. BEST PRACTICE FOR ISSUING NOMNCs IN NON-DELEGATED NETWORK
Linda Keenan, RNC, NMCC Health Services Director
Hometown Health (Part of Washoe Integrated Health Network)
November 9, 2005

22. Best Practice for Issuing NOMNCs In A Non-Delegated Network
Product Evaluation
Linda Keenan, RN, C NMCC
Director, Health Services
Hometown Health
Reno, Nevada
November 9, 2005

23. Grijalva Regulation – First Steps
Understand the regulation
Identify participating providers affected by ruling
Develop policy and procedure for issuing NOMNCs and DENCs
Develop educational plan for participating providers
Designate Hometown Health staff to administer “Grijalva Regulation”
Develop and maintain monitoring and audit mechanism

24. Detailing the Process Understanding the Regulation
Review CMS guidelines for Grijalva
Format NOMNC and DENC to Hometown Health logo
Develop process for ongoing monitoring of NOMNC and DENC amendments
Establish information necessary to initiate an NOMNC
Establish mechanism necessary to ensure delivery of appeal rights
Establish key contact at Hometown Health Monday – Friday and on-call

25. Detailing the Process Identification of Participating Providers
Participating providers designated in the provider directory
Establish additional providers via:
Information Resources Utilization Repot
Rural non-contracted provider utilization history
Non-contracted out of area providers are monitored by the RN Home Health Case manager via the concurrent authorization process

26. Detailing the process Development of Policies and Procedures
Policy and Procedure developed for:
SNF
Home Health
(No CORF in Northern Nevada)
QI0 Appeal
Request for NOMNC form (attached)
Includes:
Delivery of NOMNC
Delivery of DENC
Provider Accountability
Hometown Health Accountability
QI0 on-call accountability 24/7

27. Detailing the Process Provider Education
Establish date for completion of provider education
On-site and telephonic conferences
Discussion of ruling and implementation plan
Overview of handouts (in person or via fax)
Policy and procedure for NOMNC administration
Use of “Request for NOMNC tool”
Consistent follow up by Hometown Health for further education and correction of delinquencies

29. Detailing the Process
Designation of staff to administer “Grijalva Regulation”
Clerical
Receipt of NOMNC request tool
Initiation of NOMNC
Entry of data onto NOMNC audit log
Logs returned NOMNC for filing
Certifies mail for follow-up notification RN
On-site delivery of NOMNC in SNF setting
Monitoring of concurrent authorizations for SNF & Home Health
Backup for Director for QI0
Director
Audit log reviewed monthly
Ongoing education
24/7 contact person for QI0

30. Detailing the Process Monitoring and Audit Mechanism
Development of Excel log/spreadsheet and on-line letter database
Inclusion specifically of:
Date NOMNC to be given
Date termination of service date
Reason for denial
Date copy of letter received in office
Accountability on behalf of provider to return letter within 48 hours and certification notice as applicable
Accountability on behalf of Hometown Health to have designee contact provider if outside of 48 hours receipt timeline
Daily review of log to establish delinquencies
Monthly audit of log with contact to providers to correct any delinquencies

31. BEST PRACTICE FOR ISSUING NOMNCs IN DELEGATED NETWORK
Louise MacDonald, RN, BSN Director QI, UM, CCM
SCAN Health Plan
November 9, 2005

32. Our Mission and Vision
SCAN will become the leading geriatric-focused health management enterprise in the country. Its mission is to continue to find innovative ways to enhance seniors' ability to manage their health and to continue to control where and how they live.
We will achieve this mission by developing partnerships that allow us to deliver the right healthcare, in the right setting, and at the right cost while maximizing the seniors' ability to remain independent.

33. Network Relationships
Health Plan
Physician Organizations
Contracted Ancillary Vendors
SNF HH
CORF

34. Network Relationships
Successful partnerships – essential to success with compliance
How to help one another succeed?

35. Network Relationships
Health Plan and Physician Organization Partnership
Health Plan is ultimately responsible for CMS regulation compliance
Physician Organization is responsible for issuing and delivering the NOMNC and DENC

36. Physician Organization and SNF/HH Partnerships
Decisions to be made by the Physician Organization and the SNF/HH
Who completes the NOMNC?
Who delivers the NOMNC?
Who is responsible for the documentation of the NOMNC delivery
Who completes and delivers the DENC?

37. Focus on Success SCAN Health Plan’s Focus
Compliance Success for our Business Partners
Compliance Success for ourselves
Compliance everyday

38. Actions for Success SCAN Health Plan Audit
Identify Areas for Improvement
Education
Communication
Tools
Incentive

39. Actions for Success Audit By SCAN Health Plan Monthly
CMS audit worksheets
CMS audit methodology
CMS scoring method

40. Actions for Success Identify Areas for Improvement
For each Provider Organization
For non compliant elements
Provide monthly reports that include
Compliance scores for each element
For non-compliant elements
the regulation citation
Corrective Action (canned text)
Corrective Action specific to the Notices audited

41. Actions for Success Education
Monthly individual telephone in-services for non-compliant elements
On site in-services as needed
Annual Network Inservice hosted at SCAN

42. Actions for Success Communication New/revised regulations
Revised Notice templates
Quarterly Newsletter “Service Denial Update”

43. Actions for Success Tools Provide tools to facilitate compliance
ICE web site
SCAN tools
SCAN Ancillary Provider Operations Manual
Coaching – SCAN Denial Oversight and Appeals staff are available to answer questions

44. Actions for Success
SCAN Network Management Provider Service Interventions
Working with Physician Organization Management staff and contracted SNFs to resolve barriers to success

45. Actions for Success Physician Organization Incentive Program
Monetary reward for compliance with Denial Notices

46. NOMNC and DENC Templates

47. Notice of Medicare Non-Coverage (NOMNC)
ICE Template approved by CMS Central Office and CMS Region IX

48. Notice of Medicare Non-Coverage (NOMNC) pg. 2

49. Attachment (Optional) (to assist with documentation)

50. Detailed Explanation of Non-Coverage (DENC)

51. TOOLS For electronic copies email to qmumdepartment@scan healthplan
TOOLS For electronic copies to healthplan.com subject: tools

52. Notice of Medicare Non-Coverage
From SCAN Ancillary Provider Operations Manual.
Provides a brief description for NOMNC valid delivery.

53. NOMNC / DENC Instructions
From SCAN Ancillary Provider Operations Manual.
Provides a narrative description of NOMNC and DENC process including documentation needed for an appeal.

54. NOMNC / DENC Instructions pg. 2

55. Telephone Notification Check List
This checklist could be used to document valid delivery of the NOMNC.

56. Acknowlegements
On behalf of myself and SCAN we would like to acknowledge the three Physician Organizations that were selected by CMS for the 2005 audit. SCAN extends its gratitude and appreciation for their stellar performance.
Alamitos IPA
Axminster
Family Seniors

57. Best of Health
Regards,
SCAN Health Plan

58. Best Practice for Effectuation of QIO Decision Reversals
Susan Tenorio, BSN, RN
Director, Health Services
Inter Valley Health Plan
Pomona, California
November 9, 2005

59. Effectuation of the QIO Decision Reversals
Communication
Assessment of Decision
Reasons for Overturning
Documentation
Notice of Reinstatement Letter
Process Improvement
Evidence
Process Flow

60. Communication Verbal notification from Lumetra
Plan informs group
Written notification from Lumetra - usually within one week
Written notification forwarded to group

61. Reasons for Overturn Technical Reasons Continued Skilled Need
Non-compliant submission timeframes
Non-Compliant language in NOMNC
Poor documentation of verbal notification to member’s representative
Continued Skilled Need
Patient clearly needs to continue SNF
Patient not fit to be discharged

62. Assessment of Decision
Merits of decision analyzed
Technical Reasons
Non-compliant timeframes
Wrong language in NOMNC
Administrative issues
Medical Necessity/Continued Need for Skilled
Patient clearly shows need to continue SNF
Medical necessity

63. Documentation Technical Reasons resulting in QIO reversal
Notify group
Request group to re-submit NOMNC
Medical Necessity/Continued Need resulting in QIO reversal
Group contacted with a request to provide re-instatement letter to member with copy to Plan and QIO

64. Notice of Reinstatement Letter

65. Process Improvement
All appeals tracked in plan’s transaction application (FACETS)
All QIO overturns logged in same system for reporting
Tracking and trending reasons for overturns
Common or recurring issues identified and addressed with group
Training opportunities

66. Evidence
Appeals database to track and trend appeals, nature/types, and decisions
Case File reposed and maintained by Health Services Department

67. Process Flow

68. QUESTIONS???