1. No category

Denial Letter Processes
with Participation from Health Services
Advisory Group (HSAG)
Presented by Service Denial Standardization Team – Main
Service Denial Standardization Team – Medi-Cal
Appeals & Grievances Team
Colleen Anderson, LVN, BS
Melony Davis, BA
Jennifer del Villar, CHC
Novella R. Quesada, RN, BSN, PHN
Get to know your presenters
Colleen Anderson, LVN, BS
1
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Write a clear and simple understandable denial
reason
Correctly cite source of UR Criteria
Use of appropriate denial rational
Use of correct template for service denied
Refer to ICE Medicare Advantage Pre-Service
Denial Reason Matrix (Revised 10/15/10)
NOTE: Links were updated as well
[a guideline not a regulation]
Clear and concise
rationale
Correct Criteria
Clinical info
5
Lack of clinical reasoning
Heavy in medical jargon
 Criteria or guidelines are not identified
 Blended decisions
 Poor syntax
 Inadequate editing or proof reading


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2
Denial Reason
 Easy for member to understand (avoid abbreviations
and acronyms)
 CMS states reading level of member materials shall
be at 8th grade reading level or lower

http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/com109c02.pdf
UR Criteria
source
Refer to clinical information
Cite

Medicare Guidelines
[Medicare Criteria Trumps All Others]
◦ Health Plan Criteria/Guidelines
◦ Provider Group committee approved
Criteria/Guidelines
◦ National Coverage Determinations (NCD)
◦ Local Coverage Determinations (LCD)

Other Criteria
◦ Milliman Care Guidelines
◦ InterQual
Best Practices
3
A service or item, or supply for which
Medicare reimbursement is not available
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
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Hearing aids
Personal care or custodial care
Non-medical services
Alternative medicine
Miscellaneous (Non Medicare and non-plan
covered) Page 31, Reason # 58*
According to Medicare guidelines [Specify
benefit] are not a Medicare covered benefit and
is excluded from coverage under your health
plan. Please refer to the Health Plan’s Member
materials for benefit guidelines.
* Refers to ICE Medicare Advantage Pre-Service Denial
Reason Matrix
Medical Necessity vs. No Medical Necessity
Service that is reasonable or necessary, or
services or supplies that:
- are proper and needed for the diagnosis or
treatment of a medical condition
- are provided for the diagnosis, direct care, and
treatment of a medical condition
- meet the standards of good medical practice
- are not mainly for the convenience of a member or
doctor
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4
No Medical Necessity Page 32, Reason # 61
The service requested was reviewed by our
physician reviewer. According to [name of
guideline and its description used to make
the decision]. The medical documentation
received does not support the need for this
service because [insert specific patient
information]. It was determined that there
was no medical necessity for this request.
Readability
Calculate the average sentence length
(ASL) = number of words per sentence
How to calculate readability level
Flesch
Kinkaid
Calculate the average number of
of syllables per word (ASW)
FK formula: (0.39 X ASL) + (11.8 x ASW) –
15.59 = Readability level
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5
Microsoft 2003
1 Click on the "Tools" menu, then click "Options"
and click on the "Spelling & Grammar" tab.
2 Check the "Check grammar with spelling" box.
3 Check the "Show readability statistics" box, then
click "OK."
4 Click the "Spelling and Grammar" icon, which
looks like the letters "ABC" with a check mark.
Microsoft Word checks the spelling and grammar,
then displays the readability statistics.
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Click “Microsoft Office” Logo
Click “Proofing”
Click “show readability statistics”
Click “Ok”
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Based on National Coverage Determination for
Cardiac Rehab (21.10), you do not meet the
Medicare criteria. The guidelines required to
meet medical necessity is that rehab needs to be
within 12 months of a qualifying cardiac event.
Based on your medical records received, there is
no documentation of a qualifying event within
the last 12 months; therefore your request is
denied. For further treatment please schedule an
appointment with your PCP Dr. XXX at XXX to
discuss alternative options.
Readability Level:
11.7
6
Based on National Coverage Determination
for Cardiac Rehabilitation (rehab), you do not
meet the Medicare criteria. The guidelines say
medically necessary cardiac (heart) rehab
needs to start within 12 months of certain
heart problems. We reviewed your medical
records and you did not have a heart problem
that meets the criteria. Therefore, this
request is denied. Please contact your PCP,
Dr. PPP at XXX-XXX-XXXX to schedule an
appointment to discuss other options.
Readability Level:
7.8
Medicare guidelines for acupuncture state
that the use of acupuncture may be
appropriate as a second or third line
treatment for a patient not responding to
conventional management or not tolerating
medication or experiencing recurrent pain.
Based on the submitted medical information,
our Medical Director cannot determine what
treatments you have already tried and failed.
Acupuncture may be considered if you have
tried other treatments and they have not been
effective. You may contact your PCP, Dr. XXX
to discuss care alternatives.
Readability Level:
13.7
Medicare guidelines for acupuncture say it
can be used only if other treatments are not
working. Patients must first try other
methods such as medication or therapy.
Your medical records do not say what
treatments did not work for you. Our
medical director has denied your request
for acupuncture. Please call your doctor, Dr.
X, to discuss treatment options.
Readability Level:
7.8
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Novella R. Quesada, RN, BSN, PHN
 Identify
when to deny service if not covered
by Medicare
 Determine if a denial letter is required
 Identify difference in Turn-Around-Time
(TAT)
 Identify when to use Informational Letter
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http://www.dhcs.ca.gov/services/medical/Pages/MediBen_Svcs.aspx
http://www.medicaid.gov/
8
PMG responsible for Medicare and Health Plan
responsible for Medi-Cal
If not covered by Medicare verify Medi-Cal coverage
If not covered by Medicare but covered by Medi-Cal
forward authorization request to HP for Medi-Cal
authorization.
Do not use Informational letter – Medi-Cal coverage is not
a carve out.
**Remember TAT for Medicare is 14 days, Medi-Cal is
5 business days.**
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Services not covered by Medicare that Medi-Cal does cover
 Shower rail
 Hearing aid
 Incontinent supplies
 Shower chairs
 B/P cuff
 Compression stockings
 Medicare covers for weeping wounds only
 Medi-cal covers for diabetics and lymphadema
 Non-Emergency Medical Transportation
 Medicare covers from home to dialysis – ambulance only
 Medi-Cal covers for specific non-emergency services
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Clear and Concise

Denial Rationale
◦ Understandable to members
◦ Reading Level
 6th grade or lower [Medi-Cal]
 8th grade or lower [Commercial]
◦ Clear and Concise explanation of the reasons for
decisions
◦ Refer to name and source of the benefit provision,
guideline, protocol or other similar criterion on which
the denial decision is based on
 Milliman Care Guidelines for MRI of the knee
 Interqual Criteia for Physical Therapy
 XXX Medical Policy for Gastric Bypass
 American Society of Gastroenterology guideline for
follow-up Colonoscopy, etc.
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9
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The treatment is determined not to be
medically necessary or does not meet UM
criteria
Not enough medical information was received
to determine if requested service is medically
necessary
◦ You must refer to the service requested and cite the
criteria not met based on the information provided

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The treatment is not a covered benefit
The proposed length of stay does not meet
our UM criteria
Specify name and source of criteria
Specific to member’s condition
Clear, concise and simplified
Refer to ICE Medi-Cal Denial Matrix
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Notice of Action(NOA)
Templates & Attachments & Attachments
Notice
•Denial
Of
•Modify
Action(NOA)
•Delay
•Terminate
•Your Rights
In addition
•State Fair
to NOA
Hearing
Request Form
•Language
Assistance
Form
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10
31
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Informal pend during decision timeframe
◦ Phone calls, e-mails, messages for clarification and
additional information by fax
◦ Only contact with provider
◦ Does not delay decision
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Formal pend before time runs out
◦
◦
◦
◦
◦
Use layperson language
Be specific to member and provider
Details, details, details
Avoid extra effort/time/touches
Ex: Consult report from Dr. X; Lab reports from 1/12
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All examples can be applied to both
Commercial and Medi-Cal/Medicaid
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DenialRational– Sample1
Reviewofyourmedicalinformationindicatesthatyouhavenot
mettheclinicalcriteriaforCTofthesinuses.PerXXXGuidelines
forCTscanofthesinuses:ChronicSinusitis/Rhinosinusitis 2
*SINUSITIS/ RHINOSINUSITIS *Definedassignsandsymptoms
ofsinusitis thatlastfor12weeksorlonger*Imagingusedto
corroboratethediagnosisand/orinvestigateforunderlying
causesofchronicsinusitis*Clinicians shouldassesspatients
withchronicsinusitis/rhinosinusitis forfactorsthatmodify
management,suchas,immunocompromised states,ciliary
dyskineallergic rhinitis,cysticfibrosissia andanatomic
variationsCOMMONDIAGNOSTICINDICATIONSFORSINUSCT:
*NASALAIRWAYOBSTRUCTIONREFRACTORYTOMEDICAL
THERAPY.Thisdeterminationwasmadebaseduponourreview
ofyourhealthconditioninrelationtoXXXCriteriaforCTofthe
Sinusesmedicalnecessitycriteriaorguidelines.Foradditional
informationandyourfuturehealthcareneeds,pleasecontact
yourPrimaryCarePhysician.
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Reading level at 23.4
Heavy on Medical Jargon
Confusing to the member
Unclear why request is being denied
35
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We cannot approve your request for a CT
scan of your sinuses. Based on the records
we received, this scan is not medically
necessary for you. A CT scan is medically
necessary for sinusitis (swelling of the
sinuses) when symptoms have not gotten
better after 3 to 4 weeks of treatment, when
symptoms last more than 12 weeks, or when
you have sinusitis more than 3 times a year.
Your records do not show that you have had
any of these problems. We based this
decision on the XXX Guideline for Computed
Tomography (CT) Paranasal Sinus and
Maxillofacial Area.
FK6.0
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XXX guidelines for botox injection indicate are only
used to treat blepharospasm, facial nerve, hereditary
spastic parapherisis, idiopathic torsion dystonia,
cerebral palsy, multiple sclerosis, neuromyletis optica,
organic writer’s cramp, orifacial dyskinesia, schilder’s
disease, spastic hemiplegia, spasticity related to stroke,
spinal cord injury, or traumatic brain injury,
symptomatic torsion dystonia or other forms of upper
motor neuron spasticity. Based on the medical
information provided, you have been diagnosed with
fibromyalgia (chronic pain) which does not meet XXX
HMO’s criteria, therefore the service has been denied.
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 Corrected
Rationale

Denial
We cannot approve your request for
Botox injection. This treatment is
not medically indicated for your
condition of chronic pain (pain that
last for a long time) caused by
fibromyalgia. Based on XXX criteria
for Botox Injection, Botox is not
indicated to treat fibromyalgia.
Botox is for certain nerve diseases
that you do not have. For more
information and your future
healthcare needs, please contact
your PCP.
FK5.4
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ICE Denial letters
Commercial
http://www.iceforhealth.org/library.asp?sf=&scid=702#scid702
Medicare
http://www.iceforhealth.org/library.asp?sf=&scid=2431#scid2431
Medi-Cal
http://www.iceforhealth.org/library.asp?sf=&cid=305#cid305
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FAQ for this session will be posted at
http://www.iceforhealth.org/viewfaqsall.asp
Pending items requiring regulatory or accrediting body
input may be posted at a later date.
ICE SDS – Main meets 1st Wednesday of even months
(Feb, Apr, Jun, Aug, Oct, Dec.) from 1:00 – 3:00
pm.
Medi-Cal Team meets the 2nd Thursday from 2:003:00 p.m. (team on hiatus at this time)
Appeals & Grievance Team – Meets every quarter
Please join a team to receive broadcasts
41
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To contact the leads of this ICE Team - Access
the Teams page on the web site via the following
link;
http://www.iceforhealth.org/teamactivities.asp
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Expedited Determinations
Cheryl Cook, RN
Project Director, Beneficiary and Family
Centered Care
Health Services Advisory Group of
California, Inc. (HSAG)
Objectives
 Determine when it is appropriate to give the
Notice of Medicare Non-Coverage (NOMNC).
 Explain the reconsideration process and how the
process affects the provider and the patient.
 Explain the barriers to effective delivery of the
NOMNC.
 Demonstrate how to complete the generic
NOMNC with all the documentation required by
CMS.
2
11/20/2012
Impact on Beneficiaries and Providers
Beneficiaries
 Gives notice of impending discharge
 Protects the rights of Medicare beneficiaries
 Establishes financial liability
Providers
 CMS audits the process
 Invalid notices cost money, waste time, and can
confuse patients
11/20/2012
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Health Services Advisory Group
–1–
Expedited Determination
Process Overview
 The provider or the Medicare Advantage
(MA) plan issues the NOMNC.
 The beneficiary or representative calls to
initiate an appeal review.
 HSAG requests the medical record.
 The record is reviewed by a California
physician.
 All involved parties are notified of the
decision.
4
11/20/2012
Responsibilities of the Provider
 The NOMNC is issued when ALL skilled
services are no longer required.
 Even if the beneficiary agrees with the
discharge, ISSUE the notice!
5
11/20/2012
When the NOMNC is Not Required
 Admission to higher level of care
 Unsafe environment – (such as unsafe
neighborhood with home health)
 Patient moves out of the area
 Patient signs up for hospice
 Patient exhausts their benefits
11/20/2012
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Health Services Advisory Group
–2–
QIO Availability
 QIO accepts patient requests for an
appeal reviews 24 hours/a day, 7
days/a week, 365 days/a year.
 After business hours, voicemail system
is in place.
 QIO performs reviews every day of the
year, including holidays.
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11/20/2012
Obtaining the Notices
www.cms.gov/BNI
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11/20/2012
NOMNC
11/20/2012
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Health Services Advisory Group
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Validating the Notice
 HSAG is required to validate the
NOMNC when the appeal is requested
 The following may invalidate the
NOMNC
–
–
–
–
Expired form (outdated)
Wrong time frames
Wrong dates
Wrong QIO phone number
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11/20/2012
Timing Requirements
 Providers
– Skilled nursing facility (SNF): Notice issued
two days prior to planned discharge
– Hospice: Hospice issued second to the last
visit
– Home Health (HH) / Comprehensive
Outpatient Rehabilitation Facility (CORF):
Notice issued on the next to the last visit
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11/20/2012
Time Frames
 Medicare beneficiaries/members have until 12 p.m. (local
time) the day before the effective date to request a timely
appeal.
– MA member requests received after that time will be referred back to health
plan.
 The QIO will request medical information from
providers/health plans.
 Providers/health plans are required to send requested
medical information to the QIO by COB on the day of
request.
– HSAG will make several attempts to obtain medical information before
reaching a final decision.
 The QIO will make a decision within one day after receipt of
all medical information.
– HSAG has met/exceeded CMS’ review timeliness threshold (≥ 95%).
11/20/2012
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Health Services Advisory Group
–4–
Reconsiderations
 For Fee-for-Service (FFS) beneficiaries,
Maximus completes the second review.
 For MA beneficiaries, HSAG completes the
second review.
– When HSAG does the second review, a physician
not involved with the original decision reviews the
chart.
 If the reconsideration is unfavorable to the
beneficiary, they can appeal to the
Administrative Law Judge (ALJ).
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11/20/2012
Issues Related to Delivery
 Patient won’t sign NOMNC
 Patient is unable to make decisions/
speak for himself/herself
– Need to speak with patient’s representative
• Legal types (e.g., Power of Attorney,
Healthcare surrogate, etc.)
• State law definition (e.g.,Next of kin, etc.)
 Representative delays
– Will not answer/return calls
– Gives excuses
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11/20/2012
Tips for Success
 Develop internal process, stick to it
 Educate all staff members regarding appeal
process
– Staff needs to know who/what HSAG is
– Staff needs to be familiar with notices, where to
find notices
– Staff needs to know they can send PHI to HSAG
 Use current version of NOMNC
– Obtain from www.cms.gov/bni
11/20/2012
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Health Services Advisory Group
–5–
Tips for Success (cont.)
 Copy of NOMNC
– Beneficiary
– Medical record
 Ensure HSAG has your organization’s appeal
contact information
 Submit requested information as quickly as
possible to HSAG
– By COB on day of request
– HSAG will make courtesy calls to providers
 Consistent, concise documentation found in
medical record
11/20/2012
– Inconsistent documents do not provide clear picture
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Tips for Success (cont.)
 Discharge plan
– Next steps for patient
– Poor planning – one of the common drivers
for readmissions
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11/20/2012
Common Drivers for Readmissions
 Lack of standard discharge processes
 Lack of engagement or activation of patients
and families
 Patients call 911 or return to emergency
departments instead of accessing a different
type of medical service
 Ineffective or unreliable sharing of relevant
clinical information
 Patients did not understand/did not correctly
take medications
11/20/2012
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Health Services Advisory Group
–6–
Common Elements of Safe and
Effective Care Transitions
 Medication reconciliation occurs.
 Patients and caregivers are involved and
prepared.
 Person-centered care plans are communicated
in a timely manner across settings.
 The sending provider maintains responsibility for
the patient’s care until the receiving clinician/
location confirms the transfer and assumes
responsibility.
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Medicare FFS Readmission Data
April 2011 to March 2012
California All‐Cause 30‐Day Readmission Rates Setting Discharged To
Number of Discharges
Number of
% of 30‐Day 30‐Day Discharges Readmits to Readmit Readmitted another Rate
within 30 Days
hospital Home 392,005 Skilled Nursing Facility 176,345 67,985 40,139 17.3% 22.8% 26.1% 26.4% Home Health Agency Hospice Other All 25,553 582 10,897 145,156 20.6% 3.7% 20.5% 19.1% 21.8% 35.9% 41.0% 26.6% 123,903 15,771 53,076 761,100 20
11/20/2012
Medicare FFS Readmission Data
April 2011 to March 2012
Number of Days from Discharge to Readmission
Setting Discharged To
Home Skilled Nursing Facility Home Health Agency Hospice Other All 11/20/2012
Number of
1‐7 8‐14 Days
Readmissions Days
67,985 36.1% 24.7%
15‐21 22‐30 Days
Days 19.4% 19.8% 40,139 32.5% 26.2% 20.5% 20.9% 25,553 36.0% 26.2% 19.4% 18.5% 582 10,897 145,156 43.0% 23.7%
38.6% 22.1%
35.3% 25.2%
17.2% 16.2% 17.9% 21.4% 19.6% 20.0% 21
Health Services Advisory Group
–7–
Conclusion
 Beneficiary has right to request review
of pending discharge/termination of
skilled services.
 NOMNC is the form to use.
 Poor discharge planning can lead to
readmissions.
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11/20/2012
Contact Information
Cheryl Cook, RN
Project Director, Beneficiary and Family Centered Care
813-865-3545
Jennifer Wieckowski, MSG
Program Director, Care Transitions
818-427-4378
Medicare Quality Improvement Organizations convene providers, practitioners, and patients to build and share knowledge,
spread best practices, and achieve rapid, wide-scale improvements in patient care, increases in population health, and decreases in
healthcare costs for all Americans.
www.hsag.com
11/20/2012
This material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy. Publication No. CA-10SOW-7.2-092412-01, FL-10SOW-2012FS3T10-11-342
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Health Services Advisory Group
–8–