[SKILLED NURSING FACILITY LETTERHEAD] (Must be issued for all SNF discharges) SKILLED NURSING FACILITY EXHAUSTION OF MEDICARE BENEFITS

Transcription

1 [SKILLED NURSING FACILITY LETTERHEAD] (Must be issued for all SNF discharges) SKILLED NURSING FACILITY EXHAUSTION OF MEDICARE BENEFITS (Hand deliver to HMSA 65C Plus Member one day prior to effective date Acknowledgment of Receipt Required) [Date] [Name of HMSA 65C Plus Member] [or Member s representative] [Address] HMSA 65C Plus Member (Patient) Name: Health Plan Name: HMSA 65C Plus Skilled Nursing Facility Name: Admission Date: Member ID#: Attending Physician s Name: Dear [HMSA 65C Plus Member s Name]: This notice is to inform you that HMSA 65C Plus has determined that effective [insert future date] your continued care in the above skilled nursing facility will not be covered. As of that date, you will have exhausted your Medicare and HMSA 65C Plus Skilled Nursing Care benefit. HMSA 65C Plus covers up to 100 skilled nursing facility days in each benefit period, according to Medicare coverage guidelines (Section 1812(a)(2)(A) and (b)(2) of the Social Security Act and 42 CFR and (b)). Our records indicate that HMSA 65C Plus will have covered 100 skilled nursing days during your current benefit period as of the above effective date. You will not be financially responsible for the services rendered from [insert date when SNF benefit period began, usually date of admission] through [insert date one day prior to effective date]. If you remain in this skilled nursing facility after the date your benefits expire, you will be financially responsible for all services provided by this facility except for those services authorized or arranged for by your personal care physician for which you are eligible under Part B of Medicare. You Have a Right to Appeal You can appeal if you believe the determination or application of your benefit coverage is incorrect. You may appeal as noted below: HMSA Provider Handbook for Health Care Facilities SNF Exhaustion of Medicare Benefits 6-23

2 Standard (60-day) and Expedited (72-hour) Appeal Processes (Use 12 Point Font) HMSA 65C Plus has 60 days to process a standard appeal. In some cases, you have the right to an expedited, 72-hour appeal. You can get a faster, expedited appeal if your health or ability to function could be seriously harmed by waiting for a standard appeal, which may take up to 60 days. If you request an expedited appeal, HMSA 65C Plus will evaluate your request and medical condition to determine if your appeal qualifies as an expedited, 72-hour appeal. If not, your appeal will be processed within 60 days. You may file an oral or written request for a 72-hour appeal. Specifically state that you want an expedited appeal or 72-hour appeal or that you believe your health could be seriously harmed by waiting for the standard appeal. If any doctor asks HMSA 65C Plus to give you a fast appeal, or supports your request for a fast appeal, HMSA 65C Plus must expedite your appeal. 10-Day Extension An extension up to 10 calendar days is permitted for a 72-hour appeal, if the extension of time benefits you, for example, if you need time to provide HMSA 65C Plus with additional information or if HMSA 65C Plus needs to have additional diagnostic tests completed. How To File an Appeal If you disagree with this determination, you can appeal to either HMSA 65C Plus, the Social Security Administration or the Railroad Retirement Board office. (If you file a request through the Social Security Administration or the Railroad Retirement Board, that office will transfer your request to HMSA 65C Plus for processing. If HMSA 65C Plus does not rule fully in your favor, your appeal will be forwarded to the Health Care Financing Administration s contractor (CHDR) for an independent decision. CHDR will send you a letter with their decision. CHDR is required to review cases forward by HMSA 65C Plus according to the same timelines that HMSA 65C Plus had to review your appeal. For example, in those cases that have been filed as 72-hour appeals, CHDR will also send you its decision in writing within 72 hours of the receipt of your case by CHDR. If you disagree with the decision issued by CHDR and the amount in controversy is $100 or more, you may request a Medicare hearing before an Administrative Law Judge (ALJ). If you remain dissatisfied with the ALJ decision, the next level of appeal is a review by the Departmental Appeals Board (DAB). Lastly, if you are not satisfied with the outcome of the review by the Departmental Appeals Board, and the amount in controversy is $1,000 or more, you may request a review by a federal district court. If you have an urgent request, specifically state that: I want an expedited appeal, fast appeal or 72-hour appeal. (Note: These urgent/expedited requests must only be made to HMSA 65C Plus.) Address and Phone Number for Filing Appeals Oral Requests for Expedited Appeals: Call HMSA 65C Plus at or your local HMSA office; HMSA 65C Plus s Teletype Device for the Deaf (TDD) at HMSA 65C Plus will document the oral request in writing SNF Exhaustion of Medicare Benefits HMSA Provider Handbook for Health Care Facilities

3 Fax Requests for Standard or Expedited Appeals: FAX to: HMSA 65C Plus at If you are in a hospital or a skilled nursing facility, you may request assistance in having your written appeal transmitted to HMSA 65C Plus by use of a FAX machine. Written Requests for Standard or Expedited Appeals: Write to: HMSA s Claims Administration Department Attn: HMSA 65C Plus Appeals P.O. Box 2410 Honolulu, HI Note: HMSA 65C Plus s time limit for review of your appeal will not begin until your request for appeal is received. Time Limit for Appeals You must file your request within 60 days of the date of this notice. THE FOLLOWING INFORMATION APPLIES TO BOTH STANDARD (60-DAY) APPEALS AND EXPEDITED (72-HOUR) APPEALS Support for Your Appeal You are not required to submit additional information to support your request for services or payment for services already received. HMSA 65C Plus is responsible for gathering all necessary medical information; however, it may be helpful to you to include additional information to clarify or support your position. For example, you may want to include in your appeal request information such as medical records or physician opinions in support of your appeal. To obtain medical records, send a written request to your personal care physician. If your medical records from specialist physicians are not included in your medical record from your personal care physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you. HMSA 65C Plus will provide an opportunity for you to provide additional information in person or in writing. Who May File an Appeal? 1. You may file an appeal. 2. If you want someone to file an appeal for you: a. Give HMSA 65C Plus your name, your HMSA 65C Plus member number, and a statement which appoints an individual (may be a friend, relative, physician or any provider) as your representative. For example: I (Your name) appoint (name of representative) to act as my representative in requesting an appeal from HMSA 65C Plus and/or the Health Care Financing Administration regarding HMSA 65C Plus s (denial of services or denial of payment for services). b. You must sign and date the statement. c. Your representative must also sign and date the statement unless he/she is an attorney. d. Include the signed statement with your appeal. 3. Non-plan providers may file an appeal if they complete a waiver of liability statement that says they will not bill you if they lose the appeal. 4. A court-appointed guardian or an agent under a health care proxy to the extent provided under state law. HMSA Provider Handbook for Health Care Facilities SNF Exhaustion of Medicare Benefits 6-25

4 Help With Your Appeal If you decide to appeal and want help with your appeal, you may have your doctor, a friend, relative, lawyer or someone else help you. There are also several groups that can help you. You may want to contact the Honolulu Elderly Information & Assistance Service at (TDD at ); the University of Hawaii Elder Law Program at ; the State Ombudsman at ; the Executive Office on Aging, Office of the Governor at ; or the Medicare Rights Center toll free at 1 (888) HMO THE FOLLOWING ARE TWO QUALITY COMPLAINT PROCESSES SEPARATE FROM THE APPEAL PROCESS DESCRIBED ABOVE Peer Review Organization Quality Complaint Process If you are concerned about the quality of the care you have received, you may also file a complaint with the local Peer Review Organization, Mountain Pacific Quality Health Foundation. Their address is: 1360 Beretania Street, Suite 400, Honolulu, HI They can be reached by telephone at on Oahu or 1 (800) from the Neighbor Islands, and their fax number is Peer Review Organizations are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. The Peer Review Organization review process is designed to help stop any improper practices. HMSA 65C Plus Quality Complaint Process You may also file a written quality complaint with HMSA 65C Plus. HMSA 65C Plus refers to this process as a grievance. The grievance process allows you to file a complaint with the HMSA 65C Plus about issues other than denied service. This process is separate from the appeal process described above. Please refer to your HMSA 65C Plus Member Handbook for details. In addition to the complaint processes described above, you may also contact the State of Hawaii Regulated Industries Complaints Office (RICO). RICO is responsible for regulating health care services plans. RICO can be reached by telephone at on Oahu, on Kauai, on Maui, and (Hilo) or (Kona) on Hawaii. If you have a grievance against HMSA 65C Plus, you should first telephone HMSA 65C Plus and use HMSA 65C Plus s grievance process before contacting RICO. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by HMSA 65C Plus, or a grievance that has remained unresolved for more than 60 days, you may call RICO for assistance. HMSA 65C Plus s grievance process and RICO s complaint review process are in addition to any other dispute resolution procedures that may be available to you, and your failure to use these processes does not preclude your use of any other remedy provided by law. Sincerely, [Insert Skilled Nursing Facility Representative signature name here on behalf of HMSA 65C Plus] 6-26 SNF Exhaustion of Medicare Benefits HMSA Provider Handbook for Health Care Facilities

5 ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE (Required for discontinuation of SNF stay) This is to acknowledge that I received this notice of Medicare coverage and appeal rights on / /, at (time) a.m. p.m. (circle one) PLEASE SIGN BELOW TO LET US KNOW YOU HAVE RECEIVED THIS NOTICE OF MEDICARE COVERAGE AND APPEAL RIGHTS. Signature of HMSA 65C Plus Member or person acting on Member s behalf Print Name (Documentation to Support Members Acknowledgment of Receipt) This is to confirm that you were advised of the initial coverage determination for the above services by telephone on / /, at (time) a.m. p.m. (circle one) Name of HMSA 65C Plus Member or Representative contacted HMSA 65C Plus Member ID# Signature of Skilled Nursing Facility Representative acting on HMSA 65C Plus s behalf Important: Copies must be sent to: 1. HMSA s Utilization Management Department, P. O. Box 2001, Honolulu, HI or faxed to Personal Care Physician & Attending Physician 3. Skilled Nursing Facility Business Office HMSA Provider Handbook for Health Care Facilities SNF Exhaustion of Medicare Benefits 6-27

6 REFUSAL TO SIGN ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE (Use 12 Point Font) If the HMSA 65C Plus Member refuses to sign and acknowledge receipt of this notice, the following information must be completed and documented. I (name of person delivering the notice) delivered this notice of Medicare coverage and appeal rights to (name of HMSA 65C Plus Member or representative). I was unable to obtain a signature on the acknowledgment of receipt. This copy of the initial coverage determination was hand delivered as noted below: [e.g., HMSA 65C Plus member refused to accept notice. Advised verbally and left copy. Also discussed with Jane Doe, his daughter], in the presence of (name of witness). The (name of HMSA 65C Plus Member or representative) was provided with a copy of this initial coverage determination on / / at (time) a.m. p.m., but refused to sign the acknowledgment of receipt notice. Signature of Person Hand Delivering the Notice Signature of Person acting as Witness of Hand Delivery Important: Copies must be sent to: 4. HMSA s Utilization Management Department, P. O. Box 2001, Honolulu, HI or faxed to Personal Care Physician & Attending Physician 6. Skilled Nursing Facility Business Office 6-28 SNF Exhaustion of Medicare Benefits HMSA Provider Handbook for Health Care Facilities