1. 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) 2 nd 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 Correct form with no 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 absolutely

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