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NOTICE OF MEDICARE PROVIDER NON-COVERAGE
OMB Approval No. 0938-0953
Patient Name: Medicare/Insurance
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Number:
The effective date coverage of your current home health services will end:
Your provider had determined that Medicare or current Health Insurance carrier will not pay for your current home health services after the effective date indicated above. You may have to pay for any home health services you receive after the above date.
Your right to appeal this decision
• You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare or current Insurance carrier coverage of these services.
• If you choose to appeal, the independent reviewer will ask for your opinion and you should be available to answer questions or supply information. The reviewer will also look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish.
• If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal.
• If you choose to appeal, and the independent reviewer agrees that services should no longer be covered after the effective date indicated above, Medicare or current Insurance carrier will not pay for these services after that date.
• If you stop services no later than the effective date indicated above, you will avoid financial liability. Should you choose to continue services you will be responsible for the cost of each visit at a rate of $347.00 dollars per visit.
How to ask for an immediate appeal
• You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services.
• Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.
• The QIO will notify you of its decision as soon as possible, generally by no later than two days after the effective date of this notice.
• Call your QIO at: Livanta, LLC (877) 588-1123 to appeal, or if you have questions. (NV) Health Insight (702) 385-9933
TOLL FREE : 1-877-LORIAN-5 (1-877-567-4265)
NOTICE OF MEDICARE PROVIDER NON-COVERAGE
Continued on from front
Other appeal rights
• If you miss the deadline for filing an immediate appeal, you may still be able to file an appeal with a QIO, but the QIO will take more time to make its decision.
• Contact 1-800-MEDICARE (1-800-633-4227), or TTY/TDD: 1-877-486-2048 for more information about the appeals process.
Additional information (optional)
Please sign below to indicate that you have received this notice.
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Authorized Representative
Form No. CMS-10123
Exp. Date 06/30/2008
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0953. The time required to prepare and distribute this collection is 5 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
C-500 PATIENT TRANSFER/DISCHARGE PROCESS
Policy
Discharge Planning is initiated for every home health care patient at the time of the patient’s admission for home health care. When the RN/therapist identifies a patient for discharge, the RN/therapist is required to contact the DOPCS and/or Clinical Manager to best determine the appropriateness of the discharge. The final determination to discharge will be per coordination and review between the clinician and the clinical manager. Additionally, RN/therapist will provide advanced notice to patient, family, and physician regarding plans to discharge/change the POC.
Purpose
1. To ensure continuity of a patient’s health care needs when the patient is discharged or transferred to another health care provider.
2. To collect data necessary for statistics, audits, and outcome measurement.
Special Instructions
1. The patient’s discharge potential shall be assessed during the admission visit. The discharge plans shall be discussed with the patient/caregiver as soon as it’s appropriate.
2. The patient’s discharge potential shall be documented on the Plan of Treatment/485.
3. The discharge plan will be discussed with the physician prior to discharge. Ongoing care needs will be identified.
4. The RN/therapist shall meet with other personnel involved in the patient’s care to review the impending discharge, ensuring that the patient meets the discharge criteria.
5. The RN/therapist shall review the electronic clinical record to assure accuracy and completion. A Discharge Plan should be developed which includes written/verbal instruction regarding the patient’s ongoing care needs and available resources.
6. The RN/therapist shall ensure that the treatment goals and patient outcomes have been met or, if unmet needs are present, the appropriate referrals are made to agencies/institutions to meet continuing patient needs.
7. Upon discharge to self-care, the patient will receive verbal/written information regarding community services, medication use, any procedures/treatments to be performed, and follow-up visits for physician care.
8. To avoid charges of “abandonment”, Lorian documentation will include the following:
•Evidence that the decision was not made unilaterally further showing that the patient, family, and physician participated in the decision to discharge patient from Lorian.
•Evidence that the patient no longer qualifies for home health care services.
•If there are unmet needs, and Lorian is no longer able to meet those needs, electronic documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated.
•Documentation of all communication with the patient, including the rationale for discharge, will be kept in the patient electronic file with copies sent to the primary physician.
Discharge Criteria:
1. Patients shall be discharged from home health services on the basis of reasonable criteria which includes:
A. The patient has reached defined goals and is no longer in need of home health care.
B. The patient’s care has become such that it is unsafe and medically inappropriate to maintain the patient in his or her home.
C. Patient is non-compliant with the established POC.
D. Medical approval or supervision has been terminated.
E. The contracting payer terminates authorization for service.
F. The patient terminates payment for service.
G. The patient chooses to use another home health care company.
H. The patient is hospitalized and the hospitalization period is greater than 14 days or exceeds the current POC certification period.
I. Patient moves out of Lorian’s service area.
J. Lorian does not provide services needed by the patient.
K. No funding is available to provide the care. Patient stays on services until other means of care is found at no cost to the patient.
L. The patient will be transferred to an acute or sub-acute care facility if the patient has demonstrated deterioration, appearance of acute symptoms, adverse effects of medical treatment, or other negative change in status occurs or if there is a threat to patient safety due to unsafe home environment, absence of physician, family, or caregiver involvement. When the patient is transferred to another facility a copy of the discharge summary will be sent to the attending physician upon request and to the facility if known. The summary will include the patient’s medical and health status at transfer or discharge from the agency.
2. The patient and caregiver will be informed of the change in status and be encouraged to provide input to the physician regarding the POC.
3. The physician will order the patient to be hospitalized, as appropriate.
Transfer Criteria:
1. In order to provide continuing care, all patients transferred to a facility will have an episode summary faxed to that facility. If a patient has had an infection during the episode, the infect report will be faxed to the facility as well.
2. The process will include: a. Identification of the transfer via hospital hold order b. A Medical Records/Clinical Manager will identify the facility the patient has been transferred to and will fax an HCHB episode summary to that facility c. The fax cover sheet will include: i. Patient Name ii. Date of Birth
3. Evidence of the episode summary having been faxed will be in the HCHB fax status report.
A MEDICARE-CERTIFIED HOME HEALTH AGENCY Serving California and Nevada
Your Lorian Team
Name: Phone: Discipline: Name: Phone: Discipline: Name: Phone: Discipline: Name: Phone: Discipline:
CLINICAL SIGN-IN SHEET
A MEDICARE-CERTIFIED HOME HEALTH AGENCY Serving California and Nevada
Your Lorian Team
Name: Phone: Discipline: Name: Phone: Discipline: Name: Phone: Discipline: Name: Phone: Discipline:
CLINICAL SIGN-IN SHEET
Your Lorian Team
***Abnormal Symptoms & VS: Dizziness,sudden numbness,headache,blurred vision, sudden confusion
Vital Signs
1.- Finger Stick is less than 60 or greater than 300
2.- BP is less than 90/50 or greater than 170/90.
3.- Hear Rate less than 50 or greater than 120
4.-Weight gain of 2 lbs in one day or 5 lbs in one week.
5.- Oxigen less than 90%
***Call your doctor or the agency. If Symptoms persist, call 911
Kaiser Foundation Health Plan, Inc
1950 Franklin Street, Oakland, CA 94612
1-800-464-4000 (TTY 711)
Notice of Medicare Non-Coverage
Date: ate. Service Start/Admission Date:
Patient Name: PatientIDNumber:
Attending Physician: Provider/Facility:
The Effective Date Coverage of Your Current Home Health Services Will End:
Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current Home Health services after the effective date indicated above. You may have to pay for any services you receive after the above date.
Your Right to Appeal This Decision
You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal.
If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish.
If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal.
If you choose to appeal, and the independent reviewer agrees services should no longer be covered after the effective date indicated above: o Neither Medicare nor your plan will pay for these services after that date.
If you stop services no later than the effective date indicated above, you will avoid financial liability.
How to Ask For an Immediate Appeal
You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services.
Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.
The QIO will notify you of its decision as soon as possible, generally no later than two days after the effective date of this notice if you are in Original Medicare. If you are in a Medicare health plan, the QIO generally will notify you of its decision by the effective date of this notice. Call your QIO at: Livanta at 1-877-588-1123 (TTY: 1-855-887-6668) to appeal, or if you have questions.
Form CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953
Y0043_N007172 File & Use (12/2013)
If you miss the deadline to request an immediate appeal, you may have other appeal rights:
If you have Original Medicare: Call the QIO listed on page 1.
If you belong to a Medicare health plan: Call your plan at the number given below.
Plan Contact Information
Kaiser Foundation Health Plan, Inc.
Attention: Expedited Appeals
Toll Free: 1-888-987-7247 (TTY 711)
Toll Free FAX: 1-888-987-2252
Additional Information (Optional):
Please sign below to indicate you received and understood this notice.
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Representative
Patient ID Number:
Date
