Mountain-Pacific Quality Health
April 2010
Benefits Improvement and
Protection Act (BIPA) §521
Federal Register, Friday, November 26, 2004
 42 CFR 405.1200-1206
 Amended section 1869 of the Social Security Act
 Requires a process in which the beneficiary may
obtain an expedited determination in response to
the termination of provider services
Expedited Determinations –
Grijalva and BIPA
 FFS Medicare Beneficiaries
 Medicare Advantage Beneficiaries
 HHAs, SNFs (includes Swing Beds, ECFs TCUs),
CORFs and Hospices (FFS only)
 Given When Coverage of Medicare Services Ends
Expedited Determinations
 2-step Notice Process (Separate forms for FFS and
Medicare Advantage)
 1st Notice (Notice of Medicare Provider Non-Coverage:
Generic Notice)
 2nd Notice (Detailed Explanation of Non-Coverage:
Detailed Notice)
 Only given if beneficiary appeals to QIO
Provider Responsibility
Medicare Beneficiary’s Rights
Before complete termination of services, the provider
must deliver a valid written notice to the beneficiary
of the decision to terminate services.
Generic Notice
 Appropriate for…
 Discharge from a residential provider
 Complete cessation of coverage at the end of a course of
treatment
 Not appropriate for…




Exhaustion of benefits
Reduction in services
Hospital transfer
Refusal of care
 Notices available online
•
www.cms.gov/bni
Expedited Determinations
 Beneficiary contact (written/phone) QIO by:
 noon the day before Effective Date on Notice
 QIO must contact provider “immediately”
 Provider must get Detailed Notice to Bene and
Mountain-Pacific by COB same day
 72 hours to render a decision, must be available on
weekends to receive peer’s decision and give
decision to facility and beneficiary.
Provider Responsibility
 Assign a designated person and at least one
back-up person to respond to QIO’s requests
for patient notices and medical records
 Staff instructions
 Appeals process
 Accessing the medical records
 Material to be faxed to QIO
 Actions based on QIO’s determination
Provider Responsibility
 Provide QIO instructions for handling appeal
requests
 Designated persons to contact in case of an appeal




review
Level of urgency
Educate all staff on appeals
The BIPA and Grijalva appeals process
Roles and responsibilities within your organization
Provider Responsibility
Content of Generic Notice




Beneficiary’s Name and HIC number
Date Coverage of Service ends
Type of coverage ending
Name and telephone number for Mountain-Pacific
1-800-497-8232
 Date beneficiary’s financial liability begins is the day after
coverage ends
 Description of right to appeal
 Description of right to detailed information
 Any other information required by CMS
Provider Responsibility
Valid Notice
 Appropriate timing of delivery
 Correct content of notice
 Beneficiary signed and dated notice
 POA receives appeal information on date notice is
given
Perfect Notice
 Correct form with no changes
All the right parts
 Displays OMB Approval number in the upper
right corner
 Describes the appeal process, including how to
contact Mountain-Pacific
 Includes the CMS form number, expiration
date, and the CMS language at the bottom of
page 2
Notice Delivery
Beneficiary Refuses to Sign
 Annotate the notice to indicate the refusal.
 The date of the refusal is the date of receipt of the
notice.
Avoiding Invalid Generic Notice
 Deliver the Generic Notice at least two days
PRIOR to the date of termination of services.
 Explain appeals process to the beneficiary or
representative.
 If the beneficiary is impaired, and the
representative is not available, mail the Generic
Notice to the patient’s designated
representative.
 If MP determines the beneficiary did not
receive a valid notice, the provider may be liable
for continued services until two calendar days
after the beneficiary receives a valid notice.
Medicare Beneficiary
Appeal Request
The beneficiary (or representative) must call
Mountain-Pacific and request an expedited appeal
by noon of the next day after receiving the Generic
Notice,
Medicare Beneficiary
Untimely Appeal
If a valid notice was issued, a non-expedited review is
performed


If services are continuing, a decision in 7 days
If no longer receiving services, a decision in
30 days
Responsibility of QIO
Determination
Notify the beneficiary (or representative), beneficiary’s
physician, and the health care provider.

Initial notification may be made by telephone.

A written notification must follow.
Responsibility of QIO
Written Notification
 Rationale for determination
 Explanation of the Medicare payment consequences and
the date the beneficiary becomes liable for services
 Information about reconsideration rights, including
how to request appeal and the time period
Detailed Notice
 Provide the beneficiary a description of any applicable
Medicare coverage rules, instruction, or other Medicare
policy rules or information about obtaining a copy of the
Medicare policy
 Facts specific to the beneficiary and relevant to the
coverage determination to advise the beneficiary of the
applicability of the coverage rule or policy to the
beneficiary’s case
 Any other information required by CMS
 Specific and detailed explanation why services are either no
longer reasonable and necessary or no longer covered
 No Beneficiary signature requirement
Medical record contents
 Hospital discharge summary
 SNF admission H&P and nursing admission
assessment
 Skilled therapy (PT, OT, Speech) admission
assessment
 Weekly skilled therapy summary reports
 Skilled therapy discharge summary (if applicable)
Medical record contents
(continued)
 Progress notes (MD, RN, PT/OT, Speech, Case




Management/Social Service)
Detailed Notice of Non-coverage
Physician’s order & medication administration
records
Lab & x-ray results
Consultation reports
Medicare Beneficiary
Reconsideration Request
 Beneficiary may request a reconsideration of
appeal
 Only the beneficiary (or representative) may ask
for a reconsideration
 Conducted by Qualified Independent
Contractors (QIC)

Prepare cases for Administrative Law
Judge (ALJ) review, if appropriate
Expedited Reconsideration
 QIC must notify MP on day request received
 MP has 2 hours to provide record to QIC
 QIC has 72 Hours from:
 receipt of request for recon and
 receipt of medical or other records
 Maximus Federal Services, Inc.
Financial Liability
 Medicare coverage continues until the date and
time designated on the valid Generic Notice, unless
MP or QIC reverses the provider’s service
termination decision.
 If MP’s decision is delayed because provider did not
supply necessary timely information or records,
provider may be liable for costs of any additional
coverage.
Financial Liability
 If MP determines beneficiary did not receive a valid
notice, provider may be liable for continued services
until two days after the beneficiary receives valid
notice.
 If MP upholds the notice, beneficiary is financially
liable for services received after the effective date.
Financial Liability
 If MP overturns the notice, Medicare will continue to
cover services.
 Providers are not to bill beneficiary for any disputed
services until the expedited determination process
(and reconsideration process, if applicable) is
completed.
Mountain-Pacific
Medicare Appeals Contacts
Chris Tabbert, RN, 1-800-497-8232,
ext. 5881, ctabbert@mtqio.sdps.org
Rhonda Finstad, RHIA, CCS, 1-800-497-8232, ext.
5892, rfinstad@mtqio.sdsp.org
Marcy Gallagher, RHIA, CPHQ, 800-497-8232, ext.
5858, mgallagher@mtqio.sdps.org