Hospital-Issued Notices of Noncoverage (HINNS) and Notice of Discharge and Medicare Appeal Rights (NODMARS)

Commonly Asked Questions

• If a patient/representative refuses a nursing home bed can the hospital issue a Continued Stay HINN/NODMAR?
• If a patient does not meet admission criteria and the attending physician does not agree with a Preadmission/Admission HINN/NODMAR, what can the hospital do?
• If a patient is in an observation bed and wants to be admitted, but criteria are not being met for admission, can the facility give a Preadmission or Admission HINN/NODMAR?
• Are there any notices to give patients who refuse to leave after an observation stay that does not require admission to the hospital?
• Can a HINN/NODMAR be given to a patient who is confused, incompetent, incapable or too sick to understand the notice?
• If a patient is requiring skilled care placement and a skilled bed is not available, can the hospital issue a HINN/NODMAR?
• If the patient has expired or been discharged, can a HINN/NODMAR be issued?
• If a patient has exhausted all available benefit days of Medicare hospitalization, can the hospital issue a HINN/NODMAR?
• If the attending physician does not concur with a Continued Stay HINN/NODMAR, can the hospital issue a HINN/NODMAR?
• If the beneficiary is incapable of transacting business and the hospital cannot reach the beneficiary's representative, how can a HINN/NODMAR be given?
• If the attending physician does not agree with a Preadmission or Admission HINN, will the QIO review the case to see if a HINN/NODMAR is appropriate?
• How long can the QIO take to review a case before making a decision on concurrence with a Continued Stay HINN/NODMAR?
• How long can the QIO take to do an immediate review of an HINN/NODMAR that a beneficiary has received?
• How long can the QIO take to do a review of a Continued Stay HINN/NODMAR if the beneficiary/representative does not ask for review until some point after noon the day following the receipt of the HINN/NODMAR and the beneficiary remains in the hospital?

A) If the patient is not requiring skilled care, it is appropriate to issue a Continued Stay HINN/NODMAR after discharge indicators have been met and the patient is unwilling to make discharge arrangements. Nursing home placement does not have to be available for a patient who does not require a skilled level of care for a notice to be appropriate.

B) If the patient is requiring skilled care, the hospital must offer an available skilled bed to the patient that the patient/representative must refuse before a Continued Stay HINN/NODMAR is appropriate. The HINN/NODMAR is not appropriate if a skilled bed is not available at the time the HINN/NODMAR is issued. If the skilled bed was offered yesterday, you should not issue a notice today unless a skilled nursing facility (SNF) bed is still available. The notice should be given only when placement is available and refused for patients requiring skilled care.

C) If a patient/representative refuses skilled placement for inconvenience reasons, i.e., the SNF is too far away to visit on a regular basis, this must be considered. The reason for the inconvenience must be adequate and is decided on an individual basis.

D) Refusal of an available bed due to financial reasons is a true problem; however, Medicare does not take this into consideration. Medicare looks only at medical necessity.

The hospital does not need the agreement of the attending physician or the quality improvement organization (QIO) to issue a Preadmission or Admission HINN/NODMAR. An Admission HINN/NODMAR may be given at any time during the stay if the admission has never been approved by the facility.

There should be an order for admission or specified intent to admit the patient from the attending physician before a HINN is considered. If there is intent to admit the patient, a Preadmission HINN/NODMAR should be given before the patient is officially admitted, if not meeting criteria. A Preadmission HINN/NODMAR will make the patient immediately liable after admitted. An Admission HINN/NODMAR issued before 3:00 p.m. the day of admission, makes the patient liable, effective that day. However, if the Admission HINN/NODMAR is not given until after 3:00 p.m. the day of admission, the patient will not be liable until the day following the day the HINN/NODMAR is issued.

HINNs/NODMARs should never be given to patients who are not able to understand what a HINN/NODMAR means and how to ask for an immediate review if they so desire. This could be a confused patient, incompetent patient, patient too sick to transact or understand business related issues, or a patient incapable of transacting or understanding business for any reason. If any of these circumstances are present, the HINN should be given to a responsible party acting on behalf of the patient. This does not mean that the responsible party is liable for the bill, only that they can take some action for the patient in regard to this HINN/NODMAR. This responsible party could be a family member, guardian, or person who has power of attorney, or, a friend. If there is no responsible party, a HINN/NODMAR may not be issued until one is found or appointed. Department of Human Resources (DHR) should be asked to appoint a guardian in cases where no one is the responsible party for patients unable to make decisions for themselves. If the patient is court committed and there is no other responsible party, a HINN/NODMAR may be issued to the court.

No. The hospital should continue to document that skilled placement is being sought and where on a regular basis, preferably daily. Medicare will cover any outlier days where the patient needs skilled care and it is documented that no placement is available.

A HINN/NODMAR may never be given to a deceased person. If the patient has already left the facility, a HINN/NODMAR may not be issued, as you cannot make a beneficiary/representative liable retrospectively (prior to the act of issuing the HINN/NODMAR).

No. If the patient has no benefit days left, Medicare is no longer paying. Therefore, it is inappropriate to issue a HINN/NODMAR telling the patient that Medicare coverage is being discontinued due to lack of medical necessity for continued stay.

A) If the hospital UR physician agrees that a HINN should be issued, the hospital should contact the QIO and ask the QIO to review the case for issuance of a Continued Stay HINN with QIO concurrence. The QIO will need to do a continued stay review over the phone or by FAX at that time. The attending physician's telephone number will be needed. The hospital must issue The Hospital to Beneficiary Notice of QIO Review of the Need for Continued Hospitalization (Exhibit 10 of Model HINN Letters) to the beneficiary/representative before the QIO can review for concurrence of a Continued Stay HINN. The QIO should be contacted with review information before 3:00 p.m. when requesting review of a Continued Stay HINN with QIO Concurrence.

B) When the MA organization allows the hospital to make the noncoverage/discharge determination (delegation), the hospital must obtain concurrence from the contracting physician responsible for the enrollee's hospital care or of another physician as authorized by the MA organization. The QIO does not review potential NODMARs where the attending does not concur.

After all reasonable efforts fail to notify the representative, the hospital may contact the representative by telephone, followed by written notification, mailed to the representative on the same day. The hospital must document the telephone and written notification and retain copies for the QIO review. For those cases, the date of telephone contact is considered the date of the receipt of the HINN/NODMAR. When direct telephone contact cannot be made, the hospital should send the HINN to the representative by certified mail, return receipt requested. The date that someone at the address signs or refuses to sign the receipt, is the date of receipt of the HINN/NODMAR. For a HINN/ NODMAR sent certified mail, return receipt requested, the receipt is returned to the hospital with no indication of a refusal date or no receipt is returned to the hospital, the hospital should determine the beneficiary's liability starting on the second working day after the hospital's mailing date (post marked) by the Postal Station.

No. The hospital may issue a Preadmission or Admission HINN without the concurrence of the attending physician. The QIO does not review Preadmission or Admission HINNs prior to the hospital issuing them.

For potential continued stay HINNs, the QIO will try to get the decision back to the hospital the same day if at all possible. In cases where the QIO is unable to reach the attending physician it may take longer. Also if the QIO does not have enough information to make a decision, the medical record may be requested for review before a decision is made. The QIO does not review potential NODMARS for QIO concurrence (see question 8).

A) Preadmission Immediate review is performed when the request is submitted by telephone or in writing within three calendar days of the receipt of the HINN/NODMAR. A notice explaining the QIOs determination and any applicable appeal rights would be sent to the provider and the beneficiary/ representative. Also, a telephone call would be made to the beneficiary/representative and the UR Department notifying all parties of the QIO determination and any applicable appeal rights immediately after review is completed.

C) For a Continued Stay HINN/NODMAR, when the request for review is submitted no later than noon the first working day after the HINN has been received, the hospital/MA organization must provide the medical record to the QIO by close of business of the first working day after the beneficiary requests review of the HINN/NODMAR. The QIO will complete the review within one full working day after the date of receiving the request and the required medical records. The QIO will notify the beneficiary/representative and hospital/MA organization of its determination initially by telephone and followed with a written notification. If the QIO agrees with the HINN/NODMAR, the beneficiary will become liable for hospitalization on the day following the QIO's determination.

The QIO will review the case within two working days following the beneficiary/representative's request and will determine QIO agreement or disagreement with the notice. If the QIO issues a denial notice (upholding the hospital's HINN/hospitals or MA organizations NODMAR), the beneficiary becomes liable on the liability date stated in the HINN/NODMAR. The beneficiary/representative and hospital/MA organization will be notified of the QIO's decision in writing and by telephone if possible.