Hospice Expedited Determination Process

Medicare Benefit Policy Manual (CMS Pub. 100-04, Ch. 30 §50.9.1)

Medicare Benefit Policy Manual (CMS Pub. 100-04) Change Request 3903

When you anticipate that hospice coverage of services will end for a beneficiary, you must notify the beneficiary that their Medicare coverage will be ending.  Notification must be made no later than two days before the effective date of the end of the coverage.  Even though revocation represents an end of covered hospice care, it cannot trigger an expedited determination since it is the beneficiary’s, not the provider’s, choice to revoke.  In addition, transfers to another hospice provider cannot trigger an expedited determination.  

Hospice agencies are required to provide a Generic Notice to beneficiaries to alert them that Medicare covered item(s) and/or service(s) are ending and give beneficiaries the opportunity to request an expedited determination from a Quality Improvement Organization (QIO.)  When the QIO review is requested, a Detailed Notice is given to the beneficiary to provide more explanation on why coverage is ending. 

*Note:  You may give both notices simultaneously if it is clear the beneficiary wants to request an expedited determination, or if the beneficiary specifically requests the detailed notice, or if the provider is not expecting subsequent face-to-face contact in the covered period.

The Generic Notice and Detailed Notice forms, as well as form instructions for completing the expedited determination are available on the Centers for Medicare & Medicaid Services (CMS) Web site.

• QIO Listing — CMS has contracted with Quality Improvement Organizations (QIOs) to review the beneficiary’s appeal of discharge.

Page last updated: May 17, 2010

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