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Home Health Expedited Determination Process

Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 30, §60.2.B & 260)External PDF

Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 1, §150.3)External PDF

The expedited determination process is afforded to Medicare beneficiaries to dispute the end of their Medicare covered services in certain settings, including home health care.

When a home health agency (HHA) determines that the beneficiary's Medicare-covered home health services are ending, they are required to provide a Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) to the beneficiary at least:

  • Two calendar days before Medicare covered services end; or
  • The second to last date of service (if care is not being provided daily).
  • For home health providers, this means the notice must be delivered no later than the next to last visit before Medicare covered services end.

Exception: When a home health beneficiary is found to no longer be homebound, the NOMNC should be provided to the beneficiary immediately.

Note: When home health services end because of physician's orders, HHAs have the option of issuing the NOMNC alone or both the NOMNC and the HHCCN. Refer to the Home Health Change of Care Notice (HHCCN) Web page for additional information about the HHCCN.

A NOMNC is not required when:

  • A beneficiary chooses to end the Medicare-covered services they are receiving;
  • Service are being reduced (e.g., HHA providing physical therapy and occupational therapy discontinued the occupational therapy);
  • A beneficiary moves to a higher level of care (e.g., home health care ends due to beneficiary being admitted to a skilled nursing facility);
  • A beneficiary chooses to transfer to another HHA during an episode while still receiving home health services from them; or
  • A HHA discontinues care for business reasons.

The NOMNC allows the beneficiary to appeal the HHA's decision to discharge them. A beneficiary who disagrees with the termination of services may request an expedited determination from a Quality Improvement Organization (QIO.)

The QIO is responsible for notifying the HHA of a beneficiary's request for an expedited determination. By close of business that day, the HHA must then give the Detailed Explanation of Non-Coverage (DENC) (CMS 10124) to the beneficiary. The DENC provides a more detailed explanation of why coverage is ending. The HHA must also supply the QIO with copies of the NOMNC and DENCs as well as all information, including medical records, that the QIO requests by close of business, that day. HHAs may choose to give both notices to the beneficiary at the same time.

Note: Upon the QIO's notification of an expedited determination, the HHA may telephone the beneficiary to provide the information contained on the DENC, annotate the DENC with the date and time of telephone contact, and file it in the beneficiary's record. A hard copy of the DENC should be sent to the beneficiary via tracked mail or other personal courier method by close of business of the day the QIO notifies the HHA.

Forms and Instructions

The NOMNC (CMS 1023) and DENC (CMS 10124) forms, as well as instructions for completing these forms, are available on the Centers for Medicare & Medicaid Services (CMS) 'FFS Expedited Determination NoticesExternal WebsiteWeb page under the "Downloads" section of the page. CMS has contracted with QIOs to review the beneficiary's appeal of discharge. A listing of the QIOs for each state may be accessed via the QIO Listing link under the "Additional Resources" section below.

Generally, the QIO must make their determination on whether the discharge is appropriate, within 72 hours of their receipt of the beneficiary's request for a review. Once the QIO decision has been made, the HHA and beneficiary are notified.

QIO Decision

When a QIO decision is favorable to a beneficiary without physician orders, the ordering physician should be made aware the QIO has ruled coverage should continue, and be given the opportunity to reinstate orders. The beneficiary may also choose another personal physician to write orders for care as well as find another service provider.

If covered home health care continues following a favorable QIO decision for the beneficiary, the HHA would resume issuance of Advance Beneficiary Notices (HHABN) and the HHCCN as warranted for the remainder of the home health episode.

When the HHA submits their claim to Medicare following a favorable QIO decision, the claim must include a condition code, which notifies CGS of the QIO's decision. The QIO's decision is limited to the discharge decision, and is binding. However, the claim may still be selected by CGS's Medical Review department for an additional development request (ADR), as the medical review process examines a much broader range of Medicare coverage regulations. Appropriate billing of the condition code on a QIO-reviewed claim ensures that the QIO's decision is considered during the medical review process. See the table below for a list and description of each condition code applicable to a QIO expedited determination decision.

Condition Code Description Used When The Claim Was Reviewed, And Also Report:
C3 Partial approval of Medicare-covered services
  • Some days of the stay or services were denied.
  • Occurrence span code (OSC) M0 in FL 35-36 and the From and To dates of the approved stay.
C4 Services denied
  • All services beyond the intended discharge date were denied.
  • OSC 76 in FL 35-36 in cases where the beneficiary may be liable for payment and the dates of service, denoting the patient liability period.
  • An appropriate patient status code indicating the patient's status with your agency as of the claim's "TO" date.
C7 Extended authorization of Medicare-covered services
  • An authorization for extending Medicare coverage for the services being provided was granted.

For additional information about the expedited determination process, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 30, §260External PDF

Additional Resources

Reviewed: 12.20.21


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