Hospice Quality Improvement Organization 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 form 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.

Forms and Instructions
The NOMNC CMS-102) and DENC CMS-10124 forms, as well as instructions for completing these forms, are available on the Centers for Medicare & Medicaid Services (CMS) FFS Expedited Determination Notices web page under the "Downloads" section of the page. CMS has contracted with QIOs to review the beneficiary's appeal of discharge. A listing of the QIOs for each state may be accessed via the QIO Directory link under the "Resources" section below.

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.

QIO Decision
Once the QIO notifies the hospice of the expedited determination request, the hospice must furnish the Detailed Explanation of Non-Coverage (DENC) 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.

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 certifying/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.

Claim Coding
If the hospice continues to provide services to the beneficiary following a QIO decision, the hospice claim must include a condition code, which notifies Palmetto GBA 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 Palmetto GBA'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.

Resources

• Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 1 §150.3 (PDF)
• Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 30 §260 (PDF)
• CMS FFS Expedited Determination Notices web page
• CMS QIO Directory is available from the CMS Quality Improvement Organizations "Overview" web page