Corporate

Hospice Expedited Determination Process

The expedited determination process is afforded to Medicare beneficiaries to dispute the end of their Medicare covered care in certain settings, including hospice care.

When a hospice agency determines that all Medicare covered hospice services are going to end for a beneficiary, the hospice must provide the beneficiary with the Notice of Medicare Non-coverage (NOMNC) (CMS-10123) at least:

  • Two calendar days before Medicare covered services end; or
  • The second to last day of service (if care is not provided daily).

Note: A NOMNC is not required in situations where the beneficiary has chosen to revoke their hospice benefits, or in cases where the beneficiary transfers to another hospice agency.

The NOMNC allows the beneficiary to appeal the hospice's decision to discharge them. A beneficiary who disagrees with the termination of services may request an expedited determination to the Quality Improvement Organization (QIO). The QIO is responsible for notifying the hospice that the beneficiary has requested an expedited determination.

Once the QIO notifies the hospice of the expedited determination request, the hospice must furnish the Detailed Explanation of Non-Coverage (DENC) (CMS-10124) to the beneficiary by close of business that day. The DENC provides a more detailed explanation of why coverage is ending. The hospice must also supply the QIO with copies of the NOMNC and DENC, as well as all information, including medical records, that the QIO requests.

The NOMNC (CMS 10123) and the DENC (CMS 10124) forms, as well as instructions for completing these forms, are available via links on the bottom of the Centers for Medicare & Medicaid Services (CMS) 'FFS Expedited Determination Notices' Web pageExternal Website, under the section titled 'Downloads'.

Generally, the QIO must make their determination on whether the discharge is appropriate within 72 hours of their receipt of the beneficiary's request for a review. Once the QIO decision has been made, the hospice and beneficiary are notified.

If the QIO extends coverage to a period where a physician's orders do not exist, the hospice cannot provide care. If the QIO decision is favorable to the beneficiary without physician orders, the ordering physician should be made aware of the QIOs decision, and given the opportunity to reinstate the orders. The beneficiary can also see other personal physicians to write orders, or find another service provider. The expedited determination process does not override regulatory or State requirements that physician orders are required for a provider to deliver care.

If the hospice continues to provide services to the beneficiary following a favorable QIO decision, the hospice claim must include a condition code, which notifies CGS of the QIO's decision. The QIO's decision is limited to the discharge decision, and is binding. However, the claim may still be selected by CGS's Medical Review department for a medical review additional development request (MR ADR), as the medical review process examines a much broader range of Medicare coverage regulations. Appropriate billing of the condition code on a QIO-reviewed claim ensures that the QIO's decision is considered during the medical review process. See the table below for a list and description of each condition code applicable to a QIO expedited determination decision.

Condition Code Description Used When The Claim Was Reviewed, And Also Report:
C3 Partial approval of Medicare-covered services
  • Some days of the stay or services were denied.
  • Occurrence span code (OSC) M0 in FL 35-36 and the From and To dates of the approved stay.
C4 Services denied
  • All services beyond the intended discharge date were denied.
  • OSC 76 in FL 35-36 in cases where the beneficiary may be liable for payment and the dates of service, denoting the patient liability period.
  • An appropriate patient status code indicating the patient's status with your agency as of the claim's "TO" date.
C7 Extended authorization of Medicare-covered services
  • An authorization for extending Medicare coverage for the services being provided was granted.
 

For additional information about the expedited determination process, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 30, §260External PDF.

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Updated: 09.21.17


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