Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 475 Date: July 19, 2013

Transcription

1 anual ystem Pub edicare Program ntegrity Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 475 Date: July 19, 2013 hange equest 8379 UBJT: P hapter 6 Guidelines Update. UY O NG: The purpose of this change request () is to update section to include referral to QO of quality of (health) care concerns. TV DT: ugust 19, 2013 PLNTTON DT: ugust 19, 2013 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =VD, N=NW, D=DLTD-Only One Per ow. /N/D N PT / TON / UBTON / TTL 6/Table of ontents eview of Procedures ffecting the DG eserved for uture Use eserved for uture Use ircumvention of PP eferrals to the Quality mprovement Organization (QO). UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; contractor s activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

2 V. TTNT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment - Business equirements Pub Transmittal: 475 Date: July 19, 2013 hange equest: 8379 UBJT: P hapter 6 Guidelines Update TV DT: ugust 19, 2013 PLNTTON DT: ugust 19, GNL NOTON. Background: The ontractor shall make appropriate referrals to the QO for quality of (health) care concerns. Quality of (ealth) are oncern is defined as a concern that care provided did not meet a professionally recognized standard of health care, O Pub , O Pub and (b). B. Policy: The ontractor shall refer Quality of (ealth) are oncerns ONLY to the QOs.. BUN QUNT TBL Number equirement esponsibility /B The shall make appropriate referrals to the QO for quality of (health) care concerns. Quality of (ealth) are oncern is defined as a concern that care provided did not meet a professionally recognized standard of health care, O Pub , O Pub and (b). The QOs will retain their responsibility for performing expedited determinations, ospital- ssued Notices of Non-overage (NN) reviews, quality reviews, and provider-requested higherweighted DG reviews. ll other initial payment determinations and claim adjustments are required to be performed by the. B X D hared- ystem aintainers V W Other

4 . POVD DUTON TBL Number equirement esponsibility None /B B D Other V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: N/ X-ef equirement Number ecommendations or other supporting information: ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Della Johnson, or della.johnson@cms.hhs.gov Post-mplementation ontact(s): ontact your ontracting Officer's epresentative (O) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers: No additional funding will be provided by ; contractor s activities are to be carried out within their operating budgets. ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. do not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

5 edicare Program ntegrity anual hapter 6 - ntermediary Guidelines for pecific ervices Transmittals for hapter 6 Table of ontents (ev.475, ssued: ) eserved for uture Use eserved for uture Use 6.6 eferrals to the Quality mprovement Organization (QO)

6 6.5.4 eview of Procedures ffecting the DG (ev. 475, ssued: , ffective Date: ; mplementation Date: ) The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DG was reasonable and medically necessary. f the admission and the procedure were medically necessary, but the procedure could have been performed on an outpatient basis if the beneficiary had not already been in the hospital, do not deny the procedure or the admission. When a procedure was not medically necessary, the contractor shall follow these guidelines: f the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission; f the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e., remove from the DG calculation), but approve the admission; f performing a cost outlier review, in accordance with Pub , chapter 4, 4210 B, and the beneficiary was in the hospital for any day(s) solely for the performance of the procedure or care related to the procedure, deny the costs for the day(s) and for the performance of the procedure; and f performing a cost outlier review, and the beneficiary was receiving the appropriate level of covered care for all hospital days, deny the procedure or service. ee Pub , hapter 1, 10 for further detail on payment of inpatient claims containing non-covered services eserved for uture Use ((ev. 475, ssued: , ffective Date: ; mplementation Date: ) eserved for uture Use (ev. 475, ssued: , ffective Date: ; mplementation Date: ) ircumvention of PP (ev. 475, ssued: , ffective Date: ; mplementation Date: ) f you suspect, during review of a claim associated with a transfer or readmission, that a provider of edicare services took an action with the intent of circumventing PP (as described in 1886(f)(2) of the ct) and that action resulted in unnecessary admissions, premature discharges and readmissions, multiple readmissions, or other inappropriate medical or other practices with respect to beneficiaries or billing for services, you shall make a referral to your Zone Program ntegrity ontractor (ZP). 6.6 eferrals to the Quality mprovement Organization (QO) (ev. 475, ssued: , ffective Date: ; mplementation Date: ) The s shall only refer Quality of (ealth) are oncerns to the QOs. Quality of (ealth) are oncern is defined as a concern that care provided did not meet a professionally recognized standard of health care. The ontractor shall follow the referral process as agreed upon in the QO- Joint Operating greement. The QOs will retain their responsibility for performing expedited determinations, ospital-ssued Notices of Non-overage (NN) reviews, quality reviews, transfer reviews, readmission reviews and, provider-requested higher-weighted DG reviews.

7 The ircumvention of PP will continue to be reported to your Zoned Program ntegrity ontactor (ZP). The quality initiatives associated with payment for performance are now the reporting source for eadmission eviews and Transfer eview data to the QOs. Non-covered benefits/services are not to be reported to the QO. ll initial payment determinations and claim adjustments are required to be performed by the. ll s are to turn off all automated edits/processes that generate a referral to the QOs prior to a complex medical review of the claim. eferrals to the QO shall be limited to Quality of ealth are issues as defined above and shall result from a clinician s complex medical review of a provider s medical documentation. f during the complex medical review process, a concern that care provided did not meet a professionally recognized standard of health care, the shall issue a payment determination and/or adjustment for the claim, complete the QO referral form, and forward the completed referral form and file(s) to the QO. f the referral form is not complete, the QO will return the file to the and request that the provide the missing information prior to the QO performing a review. non-covered service and/or procedure shall not be automatically referred to the QO. The shall make the initial payment determination and/or claim adjustment for a non-covered service or procedure in accordance with the edicare O , laims Processing anual and O , Benefit Policy anual. f during the complex medical review process, a concern that care provided did not meet a professionally recognized standard of health care, such as a medically unnecessary procedure, the claim shall be referred to the QO for quality review after payment determination and/or claim adjustment is made. The s shall not instruct providers, suppliers, or beneficiaries to refer payment issues to the QO. f the provider or supplier does not agree with the payment and/or claim adjustment decision, the shall communicate their options to follow the current process in O , requesting a reopening or an appeal. f the beneficiary disagrees with the payment decision and makes a request for reevaluation/redetermination, this will be considered a demand bill and is the responsibility of the.