MAXIMUS CHDR is pleased to re-initiate Recon Notes a quarterly by rey15315

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									     RECONSIDERATION NOTES
                                             M+CO Financial Responsibility for
                                             Emergency Medical Services Provided
                                             at a VA Facility             p. 8

                                             Coverage for Services Rendered at
                                             Religious Nonmedical Health Care
                                             Institutions                p. 9


                       Volume II, Issue 1    MEDICARE MANAGED CARE
MAXIMUS CHDR is pleased to re-initiate
Reconsideration Notes, a newsletter for
                                             & PACE RECONSIDERATION
the Medicare Managed Care & PACE                     PROJECT
Reconsideration Project. We hope that this
Newsletter will provide useful information   In September 2001, the Centers for
about the Medicare Managed Care & PACE       Medicare & Medicaid Services (CMS)
Reconsideration Project and MAXIMUS          selected MAXIMUS CHDR as the
CHDR.     Please submit your comments,
                                             Independent Review Entity (IRE) for the
questions and suggestions to:
                                             Medicare Managed Care & PACE
   Jennifer Lazenby, Newsletter Editor       Reconsideration Project. This award
   Medicare Managed Care & PACE              means MAXIMUS CHDR is serving as
              Reconsideration Project        the IRE for Medicare Managed Care &
   MAXIMUS CHDR                              PACE Reconsideration Project for the
   1 Fishers Road                            fourth consecutive contract. We are
   Pittsford, New York 14534                 pleased to be selected to serve in this
                                             important role, providing a valuable
   Telephone: 585-586-1770                   service to the Medicare managed care
   Email:jenniferlazenby@MAXIMUS.com         program.
MAXIMUS CHDR Reconsideration Process         This article will discuss changes that
Manuals for Medicare + Choice Plans have
                                             occurred within MAXIMUS CHDR and
been updated effective January 1, 2003.
Please visit the Medicare Managed Care
                                             the changes appeal parties will see in
and PACE Reconsideration Web site to find    the Medicare Managed Care & PACE
the latest updates.                          Reconsideration Project.

Web site: www.medicareappeal.com             Changes at MAXIMUS CHDR

                                             MAXIMUS, Inc.

Table of Contents:                           As you know, the Center for Health
Medicare Managed Care          &     PACE    Dispute Resolution was acquired by
Reconsideration Project:             p. 1    MAXIMUS, Inc. in 1999. Founded in
                                             1975 with the mission of “Helping
Non-Renewing Plans:                  p. 4    Government Serve the People™,”
                                             MAXIMUS is an industry leader --
Representative Documentation:        p. 5    providing a wide range of program
                                             management, information technology,
Waiver of Liability Documentation:           and consulting services to government
                                     p. 7    agencies throughout the United States.
The Company’s clients include the            CMS now requires the IRE to be ISO
Federal government, every state, and         9001:2000 certified. As part of this
every major city and county in the           certification, MAXIMUS CHDR has
nation. MAXIMUS has more than 5,000          revised and improved its Quality
employees located in more than 170           Manual, trained staff in ISO processes,
offices across the country.                  and created an Internal Audit system.
                                             We look forward to making the
The acquisition by MAXIMUS has               announcement in the future that we
brought about many positive changes          have attained the required ISO
for MAXIMUS CHDR.             We have        registration.
expanded our data system capabilities
and     enhanced     system      security.   Case Processing Timeliness
MAXIMUS CHDR has increased the
amount of information we can provide to      Under this new contract, MAXIMUS
the Centers for Medicare & Medicaid          CHDR is held to the same timeliness
Services (CMS), and consequently             standard that apply to Medicare +
increased and improved our reporting         Choice Organizations.          MAXIMUS
and monitoring capabilities. We have         CHDR must complete its review of an
worked with the MAXIMUS Center for           expedited appeal within 72 hours (with
Health Literacy to develop and field test    up to a 14- calendar day extension if it is
new Determination Letters written to the     in the enrollee’s interest). A standard
8th grade level. Accessing MAXIMUS           service appeal must be completed
customer service center, we can now          within 30 days of receipt of the case file
translate Determination Letters into over    (with up to a 14- calendar day extension
25 languages.                                if it is in the enrollee’s interest). A
                                             standard claim appeal must be
We are proud to be a part of MAXIMUS,        completed within 60 days of receipt of
Inc. and look forward to using our new       the file. MAXIMUS CHDR must be
resources as the IRE for the Medicare        timely in 95% of received cases.
Managed        Care       &      PACE
Reconsideration Project.                     Since the start of our new contract,
                                             MAXIMUS CHDR is timely in over 95%
Enhancements to the            Medicare      of received cases. We are working hard
Managed       Care      &        PACE        to    improve     upon   this  position,
Reconsideration Project                      particularly for expedited cases. We
                                             have devoted a portion of our well-
CMS has made several positive                qualified staff to work solely on
changes for the IRE in this new contract.    expedited cases.       MAXIMUS CHDR
Among other things, CMS made                 intends to maintain and improve upon
changes in its expectations of timeliness    our overall timeliness.
of the IRE’s case review, the IRE’s
responsiveness to enrollees and              Revised Process Manuals
Medicare managed care plans, and
most notably the IRE must obtain ISO         Due to some differences in processing
certification.   Each improvement is         requirements, MAXIMUS CHDR created
discussed in more detail in the              three (3) Reconsideration process
remainder of this Article.                   manuals for the Medicare Managed
                                             Care & PACE Reconsideration Project.
ISO Certification                            There is one manual for each general
                                             Medicare Managed Care plan type.


                                                                                      2
Cost plans and HCPPs should continue        MAXIMUS CHDR decision within the
to use the MAXIMUS CHDR Medicare            first paragraph and a more detailed
Managed Care Plan Reconsideration           explanation in the remainder of the
Process Manual. Medicare + Choice           letter. These letters continue to provide
plans should use the newly revised          instructions to the enrollee about further
MAXIMUS CHDR Medicare + Choice              appeal rights and information on how to
Organization Reconsideration Process        receive coverage/payment in reversed
Manual. Finally, PACE Organizations         (overturned) appeals. (See Appendix A
should follow the instructions in the       of the appropriate MAXIMUS CHDR
MAXIMUS CHDR PACE Organization              Reconsideration Process Manual).
Reconsideration Process Manual once it
has been finalized and approved by          MAXIMUS CHDR has also created an
CMS. All Manuals reflect the most           “appeal rights” brochure that will be sent
recent changes in the CMS Medicare          to enrollees with the acknowledgement
Managed Care appeals process and the        letter.   Please note that expedited
most up to date information regarding       appeals, due to their short review time,
MAXIMUS CHDR internal processes,            do not receive acknowledgement letters.
such as use of email for communication
and data collection.                                       Translation

Project Website                             CMS requires the IRE to provide the
                                            written Reconsideration Determination
CMS requires the IRE to create and          letter in the enrollee’s native language
maintain a web site dedicated to the        when requested. MAXIMUS CHDR has
Medicare Managed Care & PACE                the       capability     to      translate
Reconsideration Project. This site is       Reconsideration Determination letters in
now available and can be found at           over 25 languages. The Medicare
www.medicareappeal.com. There are           Managed        Care      Reconsideration
many new and exciting features in this      Background Data Form is revised to
web site. In addition to being able to      permit the Health Plan to request a
find all editions of the Reconsideration    Reconsideration Determination letter in
Notes, users will be able to research the   a language other than English. For
status of a case, review annual data        more detailed instructions please refer
reports, connect to useful related web      to Appendix A of the appropriate
sites and obtain the most recent copy of    MAXIMUS        CHDR      Reconsideration
all versions of the MAXIMUS CHDR            Process Manual.
Reconsideration Process Manuals.
                                            Data Collection
Improved Communications to Enrollees
                                            One of the enhancements MAXIMUS
         Determination Letters              CHDR is making in its role as the IRE, is
                                            increased data collection and reporting
CMS requires all MAXIMUS CHDR’s             capabilities.  The capacity of the
Reconsideration Determination letters to    MAXIMUS CHDR Appeal Case Tracking
be written at the 8th grade level. The      System (ACTS) is now expanded to
MAXIMUS Center for Health Literacy          capture and report much more detail
has assisted us in developing consumer      from each Reconsideration case file.
friendly Reconsideration Determination      This detail includes the type of
letters that meet this requirement. The     Organization   Determination      Notice
letters provide a quick synopsis of the     provided to enrollees, dates of the


                                                                                    3
Organization request and determination,      Reconsideration Project. Please visit
dates of the Reconsideration request         the new Project web site at
and determination, and the M+CO’s use        www.medicareappeal.com, where we
of    physician     review    in     its     will provide updates on our progress
Reconsideration process pursuant to 42       towards the completion of our ISO
CFR §422.590.                                certification  and      other initiatives
                                             discussed in this article.
Data is obtained and entered from
several    sources,    including    the
Reconsideration    Background    Data           NON-RENEWING PLANS
Form, and Appeal Officer data
abstraction from case files.     It is
                                             Some Medicare managed care plans
extremely important that the Medicare
                                             will either withdraw from the Medicare
Managed Care plans carefully complete
                                             program or reduce their service area at
the Reconsideration Background Data
                                             the end of the year. Information about
Form. Much of the information supplied
                                             plan withdrawal or reduction can be
on the Reconsideration Background
                                             found      on    the    CMS     website
Data Form is being entered into ACTS,
                                             http://cms.hhs.gov/healthplans/nonrene
as given, for reporting purposes.
                                             wal. Per CMS direction, MAXIMUS
MAXIMUS CHDR Appeal Officers will
                                             CHDR will continue to process all cases
also abstract certain data from the
                                             received from these Health Plans.
Reconsideration        case        file.
                                             MAXIMUS CHDR will not summarily
Discrepancies between what is reported
                                             dismiss cases based on the fact that
on the Reconsideration Background
                                             after January 1, 2003 the Health Plan is
Data Form and the data abstracted by
                                             no longer a Medicare managed care
the MAXIMUS CHDR Appeal Officer will
                                             plan or no longer serves the enrollee's
be reported to CMS.
                                             geographic area.
It is important to note that these reports
                                             CMS requires affected plans to continue
are provided to CMS as a means to
                                             to process expedited and standard pre-
make CMS aware of potential issues.
                                             service cases if the organization
CMS personnel determine how to use
                                             determination is made on or prior to
these reports in the monitoring of a
                                             December 31, 2002. Standard claim
Health Plan’s compliance with the
                                             cases (retrospective cases) should be
Medicare Managed Care Appeals
                                             processed if the date of service(s) in
process. However, as noted above, the
                                             appeal occur on or prior to December
source of the reported compliance data
                                             31, 2002.
is obtained from the Reconsideration
Background Data Form. It cannot be
                                             In the event that MAXIMUS CHDR
emphasized enough that Health Plans
                                             “overturns” the M+CO’s determination,
must accurately complete the form.
                                             the M+CO will be notified of its
                                             obligation to comply with a MAXIMUS
Conclusion
                                             CHDR decision through the "Notice to
                                             Comply." Compliance issues will be
There are many new and positive
                                             resolved by CMS, not by MAXIMUS
changes in the Medicare Managed Care
                                             CHDR.
& PACE Reconsideration Project.
MAXIMUS CHDR looks forward to
continuing to serve CMS as the IRE for
the Medicare Managed Care & PACE


                                                                                    4
       REPRESENTATIVE                         An appointment of representative
                                              statement does not need to be limited to
       DOCUMENTATION                          the form included in the appropriate
                                              MAXIMUS       CHDR      Reconsideration
Since a representative figuratively steps
                                              Process Manual. An appointment of
into the shoes of the enrollee, it is
                                              representative   statement     can   be
important      to     emphasize       the
                                              satisfied by such documents as a
requirements of Medicare managed
                                              properly executed and valid power of
care plans to obtain and verify
                                              attorney, health care proxy, or court-
representation documentation when an
                                              appointed guardianship. However, the
individual claims to represent an
                                              Health Plan must forward a copy of the
enrollee in an appeal proceeding.
                                              document as part of the case file.
An authorized representative may obtain
                                              Exceptions:
information about the enrollee’s claim to
the same extent as the enrollee. The
                                              Physicians Representing Enrollees for
representative        may    also submit
                                              an Expedited Appeal Do Not Need to Be
evidence, make statements about facts
                                              Appointed a Representative
and law, and make any request or give
any notice about the proceedings.
                                              If a physician (whether contracted or
Consequently, there is a need to protect
                                              non-contracted) is representing the
the enrollee’s privacy and direction of
                                              enrollee in an expedited appeal, an
his/her own affairs by ensuring that
                                              appointment of representative form is
appropriate documentation is obtained
                                              not required.
prior to initiating the appeal.
                                              Requirement for an Appointment of
A sample appointment of representative
                                              Representative Statement Can Be
statement is included in all three
                                              Waived
versions of the MAXIMUS CHDR
Reconsideration Process Manual.
                                              MAXIMUS CHDR recognizes that, as a
                                              practical      matter,     there      are
The following are guidelines for
                                              circumstances when appointment of
obtaining appropriate appointment of
                                              representative documentation cannot be
representative forms.
                                              obtained.      If an enrollee is not
                                              competent or is physically unable to sign
An Appointment of Representative
                                              the statement, it is the Health Plan’s
Statement Signed by the Enrollee is
                                              responsibility to determine whether the
Required
                                              purported representative is valid per its
                                              state’s laws.
Model Appeal Language for Enrollee
Materials and Service Denials, prepared
                                              Health Plans Are Required to Obtain
by CMS, states that if an enrollee wants
                                              the Necessary Appointment of
someone else to file an appeal on
                                              Representative Documentation
his/her behalf, the enrollee must provide
a written statement which appoints the
                                              The Health Plan is responsible for
individual as his/her representative. If a
                                              compliance with the appointment of
representative orally requests an
                                              representative   policies.      If  the
expedited appeal on behalf of an
                                              appointment    of    representative   is
enrollee, the Health Plan is still required
                                              required, the Health Plan must request
to obtain a signed statement from the
                                              the appropriate documentation. The
enrollee authorizing the representation.

                                                                                     5
Health Plan is not obligated to initiate an   substantive review of the issues. If
appeal prior to receipt of the required       MAXIMUS        CHDR      receives    the
documentation. If the documentation is        appropriate documentation, MAXIMUS
not provided, the Health Plan should          CHDR will forward the documentation to
forward the case to MAXIMUS CHDR              the Health Plan. If after performing a
for dismissal.                                substantive review, the Health Plan
                                              affirms    its   adverse    organization
It is MAXIMUS CHDR policy to dismiss          determination, the Health Plan should
all cases if the appointment of               submit the case to MAXIMUS CHDR as
representative statement is required, but     a new appeal. The Health Plan should
not present, and there is sufficient          not request a reopening of the
evidence that the Health Plan has             previously dismissed case, even if the
sought the documentation. Sufficient          Health Plan believes it had performed a
evidence usually consists of the Health       substantive review of the issues in the
Plan’s documented attempts to obtain          original case prior to MAXIMUS CHDR’s
the appointment of representative             dismissal.
statement on at least two occasions. If
case file documentation indicates that        MAXIMUS CHDR Data Abstraction
an appointment of representative              Requirements
statement was received by the Health
Plan, but is not included in the case file,   When completing the Reconsideration
MAXIMUS CHDR will use the “Request            Background Data Form, it is important to
for Information” process to obtain the        remember that the appeal request is not
appropriate documentation.         If the     initiated     until      the     required
information is not received within the        documentation is received (unless an
time allotted for responding to the           exception applies).        For example,
request for information, MAXIMUS              suppose     the     enrollee’s  daughter
CHDR will dismiss the case. This is true      requests an appeal of a denied
not only in expedited cases, but also in      authorization for a wheelchair on
standard     pre-service    cases     and     October 25 and submits a completed
retrospective claim denial cases.             Appointment of Representation form on
                                              November 1. The appeal request date
If a Health Plan improperly accepts an        that should be supplied on the
appeal request without the appropriate        MAXIMUS       CHDR        Reconsideration
documentation and forwards the case to        Background Data Form would be
MAXIMUS CHDR for reconsideration              November 1. If the Appointment of
determination, CMS has directed               Representation form is never submitted,
MAXIMUS CHDR to dismiss and return            then the Health Plan should leave the
those cases to the Health Plan.               appeal request date blank.

Documentation Received After                  Also, as part of its data abstraction
MAXIMUS CHDR Reconsideration                  responsibilities,  MAXIMUS      CHDR
Determination                                 provides CMS with information that
                                              includes whether the Health Plans
If the Health Plan receives the               started a formal appeal before
appropriate       appointment       of        acceptable               representation
representative     statement     after        documentation was received or whether
MAXIMUS CHDR dismisses the case               an appeal without proper representation
for lack of appropriate documentation,        documentation was submitted to
the Health Plan should perform a


                                                                                     6
MAXIMUS CHDR for determination                 documentation and forwards the case to
without a request for dismissal.               MAXIMUS CHDR for reconsideration
                                               determination, CMS has directed
                                               MAXIMUS CHDR to dismiss and return
                                               those cases to the Health Plan.
     WAIVER OF LIABILITY
      DOCUMENTATION                            Documentation Received After
                                               MAXIMUS CHDR Reconsideration
A non-contracted provider has the right        Determination
to request an appeal of a denied claim
provided the non-contracted provider           If the Health Plan receives the Waiver of
completes a Waiver of Liability form.          Liability form after MAXIMUS CHDR
The effect of this document is that the        dismisses the case for lack of
provider will not bill the enrollee            appropriate documentation, the Health
regardless of the outcome of the appeal.       Plan should perform a substantive
A sample Waiver of Liability form is           review of the issues.       If MAXIMUS
included in all three versions of the          CHDR       receives    the    appropriate
MAXIMUS        CHDR     Reconsideration        documentation, MAXIMUS CHDR will
Process Manual.                                forward the documentation to the Health
                                               Plan. If after performing a substantive
The Health Plan is not required to start       review, the Health Plan affirms its
the appeal process until it receives the       adverse organization determination, the
required Waiver of Liability form. If the      Health Plan should submit the case to
Waiver of Liability form is not provided       MAXIMUS CHDR as a new appeal. The
after two attempts to obtain the form, the     Health Plan should not request a
Health Plan should forward the case to         reopening of the previously dismissed
MAXIMUS CHDR for dismissal.                    case, even if the Health Plan believes it
                                               had performed a substantive review of
It is MAXIMUS CHDR policy to dismiss           the issues in the original case prior to
all cases if the Waiver of Liability form is   MAXIMUS CHDR’s dismissal.
required, but not present, and there is
sufficient evidence that the Health Plan       MAXIMUS CHDR Data Abstraction
has     sought     the    documentation.       Requirements
Sufficient evidence usually consists of
the Health Plan’s documented attempts          MAXIMUS CHDR provides CMS with
to obtain the Waiver of Liability form on      information that includes whether the
at least two occasions. If case file           Health Plan started a formal appeal
documentation indicates that a Waiver          before a Waiver of Liability form was
of Liability form was received by the          received or whether an appeal without
Health Plan, but is not included in the        the Waiver of Liability form was
case file, MAXIMUS CHDR will use the           submitted to MAXIMUS CHDR for
“Request for Information” process to           determination without a request for
obtain the Waiver of Liability form. If the    dismissal. It is important to fill out the
information is not received within the         Background Data Form as accurately as
time allotted for responding to the            possible and use the date the Waiver of
request for information, MAXIMUS               Liability form was received as the
CHDR will dismiss the case.                    appeal request date.

If a Health Plan improperly accepts an
appeal request without the appropriate


                                                                                       7
 SERVICES PROVIDED AT A                     the VA. Thus, the prohibition against
                                            payment to the VA prevails whether the
       VA FACILITY                          enrollee self-presented to the VA (e.g.,
                                            walk-in patient), was directed to go there
The Social Security Act §1814(c) sets
                                            by a treating physician, or was brought
forth the general rule that Medicare
                                            to the VA by ambulance.
payments may not be made to any
Federal provider of services for any item
                                            While the M+CO cannot be obligated to
or service which such provider is
                                            pay the VA directly for services
obligated by law, or contract with the
                                            rendered to veteran M+CO enrollees,
United States, to render at public
                                            the M+CO may be obligated to
expense. The Department of Veteran
                                            indemnify its enrollees for cost-sharing
Affairs (VA) is a federal provider of
                                            expenses assessed by the VA for
services that is obligated by law to
                                            emergency services. Federal regulation
render services to veterans at public
                                            42 CFR §422.502(g) obligates the
expense.
                                            M+CO to indemnify enrollees for
                                            payment of any fees that are the legal
CMS has clarified that an M+CO is an
                                            obligation of the M+CO for services
entity that stands in the shoes of
                                            furnished by non-contracted providers.
Medicare and is considered a federal
                                            M+COs are legally obligated to cover
provider of services for purposes of the
                                            both contracted and non-contracted
above rule. This means that the M+CO
                                            emergency services as per 42 CFR
may not use Medicare funds to pay the
                                            §422.113. Pursuant to this rule, M+COs
VA Healthcare System for VA covered
                                            may be obligated to indemnify enrollees
services rendered to veterans who also
                                            for VA imposed cost sharing, which
are M+CO enrollees. This rule prevails
                                            should not exceed member cost sharing
for   both    elective   services   and
                                            levels imposed in fee-for-service
emergency services rendered by the VA
                                            Medicare.
to veteran M+CO enrollees.
                                            The rules governing an M+CO’s
An M+CO enrollee, who is enrolled in
                                            responsibility for payment differs for
the VA Medical Benefits Plan, has dual
                                            services rendered by the VA to non-
entitlement to separate government
                                            veteran M+CO enrollees.         The rule
funded health care systems.        This
                                            prohibiting payment in the Social
means that the individual may elect to
                                            Security Act §1814(c) has no application
receive his or her health care either
                                            to non-veterans. Instead, the Social
through the VA system or through his or
                                            Security Act §1814(d) permits for
her M+CO. If the individual elects to
                                            payment to be made to hospitals not
receive routine or non-emergency
                                            contracted with Medicare for emergency
services through the VA system, the VA
                                            services     rendered      to    Medicare
would be obligated by law to pay for
                                            beneficiaries.    Pursuant to managed
those services and the M+CO would not
                                            care rules set forth in 42 CFR
be permitted to reimburse for such
                                            §§422.100 and 422.113, M+COs are
services under the same law.
                                            responsible for covering emergency and
                                            post-stabilization care services rendered
Similarly, the M+CO is not permitted by
                                            to enrollees. M+COs are obligated to
law to pay the VA system for emergency
                                            reimburse the VA for such services, and
services rendered by the VA to veterans
                                            would be expected to coordinate care of
who are M+CO enrollees. This holds
                                            non-veteran enrollees who are in a VA
true regardless as to the circumstances
                                            hospital due to an emergency as it
underlying the enrollee’s presentation to

                                                                                    8
would any other non-contracted or out-        such benefits under Social Security Act
of-network hospital.                          §1821. The election is effective on the
                                              date it is signed and remains in effect
                                              until it is revoked. Elections to receive
 COVERAGE FOR SERVICES                        benefits under §1821 are described in
 RENDERED AT RELIGIOUS                        terms of “excepted” and “nonexcepted”
                                              medical treatment. “Excepted” medical
   NONMEDICAL HEALTH                          care means medical care that is
    CARE INSTITUTIONS                         received involuntarily or is required
                                              under Federal, State or local law.
Services rendered at a Religious              “Nonexcepted” medical care means
Nonmedical Health Care Institution            medical care, other than “excepted”
(“RNHCI”) are covered services for            medical treatment, that is sought by or
Medicare beneficiaries pursuant to            for a beneficiary who has elected
Social Security Act §1852(a)(1)(A) and        RNCHI services.
implementing regulations at 42 CFR
§§403.700 to 403.756.                         To elect RHCI services, the beneficiary
                                              must attest that he or she is
A “RNHCI” is defined as an institution        conscientiously    opposed       to  the
that provides only nonmedical nursing         acceptance of “nonexcepted” medical
items and services exclusively to             treatment and that acceptance of such
patients who choose to rely solely upon       treatment would be inconsistent with the
a “religious method of healing” and for       individual’s sincere religious beliefs.
whom the acceptance of medical health         The signed election must contain a
services would be inconsistent with their     statement    that    the     receipt   of
religious beliefs. A “religious method of     “nonexcepted” medical services would
healing” means health care furnished          constitute a revocation of the election
under established religious tenets that       and may limit further receipt of payment
prohibit          conventional         (or    of RNHCI services.
unconventional) medical care for the
treatment of a beneficiary, and relies        Additionally, the beneficiary must have a
solely on religious tenets to fulfill a       condition that would make him or her
beneficiary’s total health care needs.        eligible to receive services covered
                                              under Medicare Part A as an inpatient in
For a provider to satisfy the definition of   a hospital or in a SNF. Note that in
a RNHCI, it must satisfy the 10               covering this benefit, you may not
qualifying provisions of §1861(ss)(1) of      require medical screening, examination,
the Social Security Act. The provider         diagnosis, prognosis, or treatment of
must also meet the conditions of              medical health care services if the
participation set forth in 42 CFR             beneficiary objects on religious grounds.
§§403.730 through 403.746, have a             Thus, a beneficiary who has made a
valid provider agreement as a hospital        valid election and presents to a RNHCI
with CMS in accordance with 42 CFR            for treatment of symptoms consisting of
Part 489, and must be classified as an        shortness of breath, fever, impaired
extended care hospital for payment            mobility and rapid weight loss, likely will
purposes.                                     meet level of care criteria for coverage
                                              of RNHCI services. This is because the
For a RNHCI to receive payment under          same symptoms would likely make that
the Medicare program, the beneficiary         beneficiary eligible for admission to a
must have made an election to receive         hospital or a SNF.


                                                                                       9
If you have questions regarding
coverage of the RNHCI benefit at CMS,
you may contact Marty Abeln at 410-
786-1032.




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