I am confused, for some reason I was dropped from the discussion group over the holidays and just got signed up again, so I may have missed part of the history of this discussion.
Why is the SNF taking on the responsibility of notifying the Medicare + C beneficiary of non-coverage? Having worked in the home of the HMO's- Minnesota for more than 25 years- the SNF's have not taken on the responsibility of giving the HMO denial notices. In some facilities we have used a form letter that indicates: On ___/___/ _____, your Medicare HMO _________________________________________, advised us that the services you receive will no longer quality as covered beginning ___/___/_____. The Medicare HMO will send you a formal determination as to the noncoverage of your stay after ___/___/_____. If you wish to appeal, the formal notice will contain information about how this can be done. The intermediary will inform you of the reason for denial and your appeal rights. If you read the instructions I have cut and pasted below- for Medicare C beneficiary notices- it seems clear to me that the responsibility is that of the M+CO not the SNF. As a former administrator, I would not have my staff issuing the HMO non-coverage letter or signing such documents. This is not a decision that has been made by the SNF- the SNF is only relaying the information. Theresa Lang Specialized Medical Services, Inc. Per the CMS BNI- Website http://www.cms.hhs.gov/medicare/bni/ Instructions for the CMS10003-NDP (Notice of Denial of Payment) A Medicare+Choice Organization (M+CO) is to complete and issue this notice when it denies a M+C enrollee's request for payment of a service already received. This is not model language. This is a standard form. Instructions for the CMS10003-NDMC(Notice of Denial of Medicare Coverage) A Medicare+Choice Organization (M+CO) is to complete and issue this notice when it denies a M+C enrollee's request for medical service. This is not model language. This is a standard form. M+COs may not deviate from the content of the form provided. Notice of Medicare Non-Coverage �The Advance Notice� CMS-10095-A A Medicare+Choice (M+C) provider must give an advance, completed copy of this notice to enrollees receiving skilled nursing, home health or comprehensive outpatient rehabilitation facility services not later than two days before the termination of services. This notice fulfills the requirement at 42 CFR 422.624(b)(2). This is a standard notice. M+C providers should not deviate from the content of the form except where indicated. �DETAILED EXPLANATION OF NON-COVERAGE� CMS-10095-B A Medicare+Choice (M+C) organization must provide a completed copy of this notice to enrollees receiving skilled nursing, home health or comprehensive outpatient rehabilitation facility services upon notice from the Quality Improvement Organization (QIO) that the enrollee has appealed the termination of services in these settings. This notice fulfills the requirement at 42 CFR 422.626(e)(1), and must be provided no later than close of business of the day of the QIO�s notification. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of [EMAIL PROTECTED] Sent: Thursday, January 01, 2004 8:12 AM To: [EMAIL PROTECTED] Subject: New appeals regulation I was able to find out about what I thought were new regs regarding snf denial letters.I found out ithas to do with managed medicare programs.Apparently there was a class action lawsuit brought by enrolles in medicare risk based programs.They felt the companies failed to give them a fair termination process.In Mass as of Jan 1st,our Medicare Quality Improvement Organization will conduce any appeals.The snf will now need to give the beneficiary an advanced 48 hour notice before the managed care company does..I won't get into all the details but I am sure it may differ state to state.We deal with several M-C organizations but only 1 has discussed this with us.I guess as usual,the snf has to take the lead. /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/ /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/
