Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-For-Service (FFS) Medicare and the Medicare Advantage (MA) programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers. Medicare beneficiaries have a right to request an expedited appeal seven days a week during normal business hours. Mountain-Pacific staff is on call seven days a week to take these appeals and can be contacted by calling our toll-free helpline, 1-800-497-8232, in Montana, Wyoming and Alaska, or 1-800-524-6550 in Hawaii.
FFS HINN notices
Hospitals provide hospital-issued notices of non-coverage (HINNs) to beneficiaries prior to admission, at admission or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered because it is:
- not medically necessary;
- not delivered in the most appropriate setting; or
- custodial in nature.
There are three types of HINNs that can be given
- The preadmission/admission HINN, used prior to an entirely non-covered stay.
- HINN 11, which is used for non-covered items or services provided during an otherwise covered stay, and its instructions have not yet been incorporated into Chapter 30 of the Online Claims Processing Manual.
- HINN 12, which should be used in association with the hospital discharge appeal notices to inform beneficiaries of their potential liability for a non-covered continued stay.
- Download the HINNs and instructions http://www.cms.hhs.gov/BNI/05_HINNs.asp
- Download Hospital Discharge Appeal Notices for notices used to inform beneficiaries of their right to request QIO review of discharge decisions on or after July 2, 2007.
Hospital discharge notices (Important message from Medicare)
Short- and long-term acute care hospitals must deliver the revised version of the "Important Message from Medicare" to inform Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights. Notice is required for both original Medicare beneficiaries and those enrolled in Medicare health plans. Beneficiaries who choose to appeal a discharge decision will receive a more detailed notice. The rule, notices and instructions are posted on CMS’ Beneficiary Notices Initiative Web site.
Non-hospital setting notices
Home health agencies, skilled nursing facilities, comprehensive outpatient rehabilitation facilities and hospices with patients in fee-for-service Medicare are required to notify beneficiaries of their right to an expedited review process when these providers anticipate Medicare coverage of their services will end.
Home health agencies, skilled nursing facilities, hospices, comprehensive outpatient rehabilitation facilities and swing beds are required to provide a Generic Notice to beneficiaries to alert them that Medicare covered item(s) and/or service(s) are ending and give beneficiaries the opportunity to request an expedited determination from a QIO. A Detailed Notice is given when the QIO review is requested in order to provide more explanation on why coverage is ending.
Download notices and instructions http://www.cms.gov/BNI/06_FFSEDNotices.asp
Medicare Advantage denial notices
Medicare Advantage organizations are required to complete and issue this notice when an MA enrollee’s request for service is denied or payment is denied, in whole or in part, for services already received.
Download the notices and instructions http://www.cms.gov/BNI/07_MADenialNotices.asp
Medicare Advantage expedited notices
Under the Medicare Advantage program, home health agencies, skilled nursing facilities, comprehensive outpatient rehabilitation facilities are required to provide beneficiaries with a Generic Notice alerting them that their Medicare-covered item(s) and/or service(s) are ending as well as provide them with the opportunity to request an expedited determination from a QIO. A Detailed Notice is given when the QIO review is requested in order to provide more explanation on why coverage is ending.
To download the notices and instructions, click on: http://www.cms.gov/BNI/09_MAEDNotices.asp