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Noncoverage Notifications Required by CMS for Inpatient/Outpatient (1.33)

Noncoverage Notifications Required by CMS for Inpatient/Outpatient (1.33) - Policies, Administrative, UW Health Administrative, Administration

1.33

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).


Policy Title: Noncoverage Notifications Required by The Centers for
Medicare and Medicaid Services (CMS) for
Inpatients and Outpatients.
Policy Number: 1.33
Effective Date: August 23, 2017
Chapter: Administration
Version: Revision


I. PURPOSE

Based on The Centers for Medicare and Medicaid Services’ (CMS) limitation on liability (LOL)
provisions, UW Health is required to provide prior notice to a patient when certain inpatient or outpatient
services ordered by a physician do not meet CMS’ medical necessity guidelines for the patient’s
condition. UW Health must issue one of the following inpatient notices to enable the patient to better
participate in decisions affecting his/her care and financial liability: (1) Important Message from
Medicare (IM); (2) Preadmission/Admission Hospital Issued Notice of Non-coverage (HINN);
(3) HINN 10 – Hospital Request for Expedited Review (HRR) Notice by a Quality Improvement
Organization (QIO); (4) HINN 11 – Noncovered Service(s) during Covered Stay;
(5) HINN 12 – Noncovered Continued Stay or; (6) Detailed Notice of Discharge (Detailed Notice). UW
Health must issue an Advance Beneficiary Notice of Noncoverage (ABN) outpatient notice to enable the
patient to better participate in decisions affecting his/her care and financial liability.

II. POLICY ELEMENTS

UW Health shall follow the guidelines developed by the Directors of Case Management and Access
Services and have been approved by the Compliance and Privacy Officer. The notices will define the
delivery and billing requirements to the patient.

III. FORMS

A. Inpatient:
1. Important Message from Medicare (IM) (CMS-R-193)
2. Language for Preadmission/Admission Hospital Issued Notice of Noncoverage (HINN)
3. HINN 10 – Notice of Hospital Requested Review (HHR)
4. HINN 11 – Noncovered Service(s) during Covered Stay
5. HINN 12 – Noncovered Continued Stay
6. CMS Detailed Notice of Discharge (Detailed Notice) CMS-10066


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B. Outpatient:
1. Advance Beneficiary Notice of Noncoverage (ABN) (CMS-R-131 (03/08)

IV. REFERENCES AND RELATED POLICIES

A. 42 CFR §§ 405.1205-405.128 (Expedited determination procedures for inpatient care)
B. 42 CFR §§ 411.400 - 408: Social Security Act
C. 42 CFR § 412.42(c): Social Security Act
D. 42 CRF §§ 412.42(c), (d) and (g)
E. 42 CFR § 422.622 (immediate QIO review of Medicare Advantage discharge determinations)
F. 42 CFR § 466.78 (b) (4): Social Security Act
G. 42 CFR § 476.48 (b) (4): Social Security Act
H. 42 CFR § 482.30: Social Security Act
I. 42 CFR § 489.34: Social Security Act
J. 42 CFR § 1395: Social Security Act
K. 42 CFR § 1848: Social Security Act
L. CMS Beneficiary Notices Initiative (BNI)
M. CMS Final Rule: Notification of Hospital Discharge Appeal Rights (CMS-4105-F)
(November 27, 2006)
N. CMS Manual System, Pub 100-04, Medicare Claims Processing, Transmittal 594
(Change Request 3903) (June 24, 2005)
O. CMS Manual System, Pub 100-04, Medicare Claims Processing, Transmittal 982
(Change Request 5070) (June 16, 2006)
P. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 29
Q. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30 § 80
R. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30 § 50.4.1
S. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30 § 50.7.2
T. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30 §§ 220-
220.5 (Hospital Requested Expedited Review)
U. CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30
§§ 240-240.6 (Preadmission/Admission Hospital Issued Notice of Non-coverage)
V. CMS Manual System, Pub 100-2, Medicare Benefit Manual, Chapter 1 § 10
W. CMS Manual System, Pub 100-08, Medicare Program Integrity, Transmittal 361,
Change Request 6988, December 10, 2010
X. Department of Health and Family Services HFS 107.0846(c)
Y. Detailed Notice of Discharge (Form CMS-10066)(July 20, 2010)
Z. Health and Human Service, CMS Ruling No. 95-1 (December 1995)
AA. Health and Human Service, CMS Ruling No. 96-2 (November 1996)
BB. Important Message from Medicare (Form CMS-R-193)(July 20, 2010)
CC. Medicare Coverage Database (MCD) at http://www.cms.gov/med/overview.asp contains all
NCDs and LCDs, local policy articles, and proposed NDC decisions
DD. NCDs are published at http://www.cms.gov/Manuals/IOM/list.asp on the CMS website. The
official versions of LCDs may be viewed by contractor, state, or alphabetically at
http://www.cms.gov/med/indexes.asp on the CMS website
EE. National Coverage Determination (NCD) can be found at CMS’ coverage Website at:
http://www./cms.hhs.gov/cneter/coverage.asp
FF. Part B of Title XI of the Act and the Social Security Amendments of 1983 (Public Law 98-21)
GG. The Medicare Hospital Manual, CMS-10 § §292, 295-299, A292, 414.1 - 414.11
HH. The CMS Quality Improvement Organization (QIO) Manual



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V. COORDINATION

Senior Management Sponsor: Sr. VP, CNO and Pt Care Services
Authors: Director, Access Services; Director, UW Health Home Care and Coordinated Care
Reviewer: UW Health Compliance and Privacy Officer

Approval Committee: UW Health Administrative Policy & Procedure Committee



SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer