expedited appeal connection 1-2.pub - FMQAI

Expedited Appeal ConnectionEducational Workshops—Expedited DeterminationsApril 2009Volume 1, Issue 2FMQAI will be offering educational workshops on the expedited determinations process in April andMay in the following cities:April 29 - Tampa - FMQAIMay 18 - West Palm Beach - Courtyard West Palm BeachMay 19 - Miami Beach - Courtyard Oceanfront Miami BeachMay 28 - Orlando - Orlando Marriott Lake MaryMay 29 - Jacksonville - Courtyard by Marriott JacksonvilleDetailed information about these training sessions is available at our web site www.fmqai.com. (Clickon Upcoming Events.) The workshops are generally three hours long and offer practical informationregarding completion of the notices along with different scenarios that providers may encounter whendelivering notices. CEUs are available for nurses, NHAs and social workers. FMQAI encouragesyour facility to send a representative to the workshop and learn the most up-to-date informationpertaining to this process.

Obtaining The Notices - www.cms.gov/bni

Obtaining The Notices - www.cms.gov/bniBoth the FFS and Medicare Advantage ED notices can be found at the Beneficiary Notices Initiative(BNI) web site. Mandatory use of the latest FFS forms began on November 1, 2008. FMQAI can nolonger accept expired forms. They will be returned to your facility as an invalid notice.On the FFS web page, you will find the generic notice both in Word and pdf form. There is also a noticethat is written in Spanish. The detailed notice is also offered in these formats. There are instructions forboth forms on the site. The expiration date on this form is 7/31/2011.On the MA web page, the generic notice and detailed notice are only offered in pdf form. There areinstructions for both forms on the site. The expiration date on this form is 8/31/2010.Contact Information FormFMQAI has a contact information form on the FMQAI websitelocated at http://www.fmqai.com/Healthcare-Initiatives-RT-ED.aspx.The form allows your facility to designate contacts so that we may knowwho to contact after hours and on weekends as well as your primarycontact. This allows both FMQAI and your facility to better completethe appeal process in a timely manner. If you have not filled out thecontact form for your facility, please visit our web site. Fax thecompleted form to Cheryl Cook at 813-354-0737.

How To Reissue a Notice After An Invalid NoticeThe process for correcting an invalid notice depends on whether the patient is a traditional MedicarePatient or a Managed Care enrollee.For FFS Traditional Medicare PatientsAn invalid notice must be reissued. A new notice of Medicare Provider Non-Coverage is to be given regardlessof which day the new notice is given. The effective date documented on the first notice remainsthe same on the reissued notice. However, an asterisk (*) is put in front of the date on the new notice.This asterisk corresponds to the paragraph that is inserted in the additional information section on thesecond page, which must state:• We are giving you another notice because the QIO decided the previous notice we gave you on (fillin the date prior generic notice was given) was invalid. You will not have to pay for any care youreceived until two days after you receive this notice. You must call the QIO again after receivingthis new notice if you still want the QIO to review the decision to end your Medicare coverage.Liability: The patient would incur no liability providing he/she left the facility or stopped outpatienttreatment two days after the new notice was issued, or the decision for discharge was overturned onappeal. The provide would incur liability for any time after the original effective date.For Managed Care Patients:A new notice is given and the effective date changes if the date of re-issue is after the first date the firstnotice was issued. The patient would be given a new effective date (two days after issuing the newnotice) and would need to call again if he/she wishes to appeal.For example: If the notice was given on 10/4 with an effective date of 10/6 and the notice was found tobe invalid, then after reissue on 10/5, the new effective date would be 10/7.

How To Reissue a Notice After An Invalid Notice (cont.)Liability: The patient would incur no liability providing he/she left the facility on the neweffective date or the decision for discharge was overturned on appeal. The Medicare Advantageplan would incur liability for any extra days of coverage beyond the original effective date.Due to the potential for liability for either the provider or the Managed Care Organization, it isessential that the provider understand the appeal process and the documentation required to assurethe notices are valid.For more information about this newsletter, contact:Marie Munsch - Case Review813-865-3909This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers forMedicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do notnecessarily reflect CMS policy. FL2009FONR0911164