Bulletin: 06-002 - Demand Bills and The Medicare Medical Information Form (MIF)

In an attempt to expedite the review process of Skilled Nursing Facility (SNF) demand bills, we are recommending that you complete and submit a Medicare Medical Information Form (MIF) when documentation is requested for payment determination of a SNF demand bill. A demand bill is submitted when the skilled nursing facility decides that a patient is no longer receiving a skilled level of care and the patient disagrees. The patient has the right to request a claim be submitted on their behalf. It then leaves the decision of coverage up to the Fiscal Intermediary.

The Medicare Medical Information Form (MIF) provides the details that are necessary to complete the picture of the patient's condition and the care, which is available from the corresponding claim.

Pub 100-04; Chap 1; Sec. 60 states that various elements should be included on the claim in order to process the demand bill in a timely and accurate manner. The demand bill (noncovered claim with condition code 20) should be submitted during the regular billing cycle, with the following supporting documentation to justify the decision of non-coverage for skilled services:

A copy of the SNF demand bill letter requesting a review be conducted. This letter must be signed and appropriately dated (date of first notification) by the beneficiary or his/her representative, as well as the administrative officer’s signature and date.

If the provider telephones the responsible party prior to the signing of the letter, the provider’s documentation should indicate the call as well as the time and the date that the call was made. The beneficiary’s responsible party’s signature verifies that notification was received.
A registered letter should be sent to the responsible party and the return receipt should also be sent along with the other documentation to support the demand bill (noncovered claim).

Applicable medical records and documents.
A completed “non-covered Medicare Medical Information Form (MIF) (for the same dates of service as the demand bill) signed and dated by the person who prepared it.

Completing the Medicare Medical Information Form (MIF)

Why should I complete a Medicare Medical Information Form

The Medicare Medical Information Form (MIF) will expedite the adjudication of the claim.

Time-period of the MIF = time-period of the corresponding claim

The information on the MIF must cover the time-period of the corresponding claim.

For example: If the dates of service on the claim are 9-14-05 through 9-30-05, the MIF information must also cover the same time period.

Attachments

When responding to an Additional Development Request (ADR) from the Fiscal Intermediary (FI) for a demand bill include the following:

Copy of the ADR
UB-92
Medical Records
Completed MIF

Attention!

Careful completion of this form is very important! If any required information is missing, the MIF may be returned to the provider for completion, and may delay the processing and payment of your claim.

Completion Instructions

The following table details the entries required on the Medicare Medical Information Form:

	Item	More Information
1	Patient's Room Number
2	Skilled Nursing Facility	The facility's full name, without abbreviation, *plus* its Medicare provider number.
3	SNF Admission Date	The date the patient was admitted to a Medicare skilled level of care, in a Medicare certified bed, to begin *the current covered stay.*
4	Period Under Review (From)	Admission date, OR the first date in the current billing period.
	Period Under Review (Thru)	Last covered date in the current billing period, OR date active care ended, OR Utilization Review Committee cutoff date, OR date benefits exhausted.
5	Patient's Name	Last, first and middle initial (if any)
6	HIC Number	Correct, complete Medicare number *It is crucial that this be accurate!*
7	Patient's Age
8	Patient's Address	Current, complete *home* address
9	Hospital and City	Name and address of the hospital in which the qualifying stay occurred. If no hospital stay, state: *None*.
10	Period of Hospitalization	Dates of the qualifying hospital stay. If no hospital stay, state: *None.*
11	Diagnoses for Active Conditions Requiring Inpatient SNF Care	List the patient's current diagnosis/diagnoses, date(s) of onset and pertinent surgical procedure(s) with the date(s) performed. If the patient is diabetic, please indicate Insulin-Dependent (IDDM) or Non-Insulin-Dependent (NIDDM). **Place an asterisk () before the principal hospital diagnosis*** (e.g., *fractured right hip 2/3/01, open reduction internal fixation right hip 2/4/01).
12	Diagnosis for any Chronic Condition	List only *relevant* chronic conditions. Indicate in the box whether the condition was *stable* or *unstable* at the time. If the patient is diabetic, please indicate IDDM or NIDDM.
13	Physician's Plan of Treatment Upon Admission to SNF or Subsequent Orders Following Admission. List Specific Care Ordered.	List the complete physician's orders *by dates.* Remember that these dates must cover the same period of time as the Period Under Review (Item 4 above). Indicate by checking the appropriate box whether orders were primarily written or oral. Complete the physician's name. You may submit a copy of the original physician orders, but *they must be legible* and dated to coincide with the Period Under Review (Item 4 above).
16	Ambulatory Status Upon Admission
17	Additional Comments About the General Condition of the Patient	Short comprehensive narrative
18	Description of skilled services	A complete picture of the patient and the skilled services received in the Period Under Review. Include a detailed account of progress, lack of progress or complications. If the patient is covered for Physical Therapy (PT), Occupational Therapy (OT) or Speech Therapy (ST), send *complete and legible* copies of *all* progress notes for the Period Under Review. Indicate patient status at end of Period Under Review, *giving appropriate dates, i.e.,: date patient expired, active care ended, Utilization Review Committee (URC) (what is this – should we define this before using this acronym) cut including grace days, benefits exhausted, etc. For demand billing, give reasons for noncoverage decisions by the SNF. *See An important note about dates at the end of this table.**
19	URC Action - Date and Decision of Further Stay	Dates of URC meetings and decisions about this patient.
20	Evaluation of Coverage	The provider's decision about coverage or non-coverage (only one coverage decision per MIF). *ONE OF THE BOXES MUST BE CHECKED. DO NOT CHECK "QUESTIONABLE."* (Check the NON-COVERED block when a denial letter was issued and you are submitting a demand bill.)
21	Form completed by and Date Completed	Signature of person completing this form, and date completed. *(Required)*
22	Date of Next URC Meeting
23	Physician's Comments (Optional)	Physician comments from the URC meetings.

PLEASE NOTE:

In locator #14 indicate not applicable and in locator #15 indicate the patient’s mental status during the period under review ONLY for demand bills.

When identifying dates related to the end of care, please follow these guidelines:

The date active care ended is the last day of Medicare coverage and payment, or the last day of Medicare skilled care.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PHYSICIAN/SUPPLIER STAFF. BULLETINS ARE AVAILABLE AT NO COST FROM OUR WEBSITE AT WWW.HIGHMARKMEDICARESERVICES.COM.

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