Service Denial Letter

A Service Denial letter informs Medicare members that Medicare will not provide Skilled Nursing Facility (SNF) coverage beyond the date indicated on the letter. The information in this section applies only to providers of Medicare-based plans, such as 65C Plus.

Each facility is responsible for developing a Policy and Procedure (P&P) that documents its process for issuance of the Service Denial letters. P&Ps should be updated to reflect current Centers for Medicare & Medicaid Services (CMS)/HMSA requirements.

Issuing a Service Denial Letter

When a Service Denial letter is required

There are three different situations when a Service Denial letter must be issued. Each requires a specific form, as described below:

• The member is denied admission to the SNF. The pre-service denial letter must be issued prior to requested date of admission. (Refer to Pre-service Denial [PDF])
• The member is discharged from the SNF (except when the member has died), or there is a change in level of care. The service denial letter must be issued at least 24 hours prior to date of noncoverage. (Refer to Termination of Services [PDF])
• The member's Medicare benefits have exhausted. The service denial letter must be issued at least 24 hours prior to date of noncoverage. (Refer to Exhaustion of Medical Benefits [PDF])

Note: A minimum three-day acute hospital stay is required prior to an SNF admission for 65C Plus members.

How to complete a Service Denial letter

Please follow these general guidelines when completing a Service Denial letter: A Service Denial letter must be issued (date of notice) at least 24 hours prior to the effective date of financial liability (date of noncoverage).

• Complete all blank fields on the letter.
• Fill in the attending physician's full name (e.g., John Q. Aloha, M.D.).
• Specify the date that noncoverage starts and, although not noted, indicate the discharge date and/or the date of change in level of care.
• Specify skilled services received and services needed (e.g., nonskilled care, home care).
• A Skilled Nursing Facility representative must sign on behalf of HMSA’s 65C Plus Plan.
• The signature of this member, relative or legal representative must be obtained for all Service Denial letters, including Preservice. The relationship of the signee must be noted if the member is unable to sign.
• If a signature is not obtained prior to discharge/downgrade, telephone contact must be made prior to certified mailing (date of mailing must be noted on denial letter).
• The facility should give the original Service Denial letter to the member or member’s authorized representative. Copies should be filed in the member’s medical and/or facility business office. Ensure that legible copies are sent to HMSA within one week of issuance.

Send a copy of the completed Service Denial letter to:

HMSA - Medical Management Department
P.O. Box 2001
Honolulu, HI  96805

Fax:  808-944-5611

Note: The wording of the Service Denial letter cannot be altered.

Obtaining Signatures

The Service Denial letter must be signed by the member, relative or legal representative regardless of whether the member agrees with the decision to deny services. If signed by anyone other than the member, the relationship must be noted next to the signature.

Member signs with an "X" or in a foreign language

If the member can only sign with an "X" or in a foreign language, the member's signature must be witnessed by two people. The words, "Witnessed by:" should be written beside the member's mark, followed by the witnesses' names and signatures. Witnesses must be 18 years of age or older and must write their relationship to the member or their title (if a facility employee) next to their signature.

Member is unable to sign

If the member is comatose, confused or otherwise unable to sign the Service Denial letter, a legal representative, family member or relative must sign on the member's behalf. If that person is unavailable to be advised of the initial coverage determination, telephonic notification is required and must be documented on the Service Denial letter. The signee must understand that signing the Service Denial letter does not indicate concurrence with the decision to deny care. Appeal options are available to the member, as described later in this document.

• Legal Representative: A legal representative may sign the Service Denial letter on behalf of the member. The legal representative must be appointed as an Attorney in Fact for the patient through a Durable Power of Attorney for Health Care document, named as court-appointed guardian, or authorized through a written advance healthcare directive or proof of authorization by state law.
• Family Member or Relative: A family member or relative may also sign the Service Denial letter for the member. The family member or relative must be 18 years of age or older and must indicate in writing his or her relationship to the member. The name of the family member or relative, along with the signature, date and statement of relationship to the member must appear in the available space below the member signature line.

Member refuses to sign

If the member refuses to sign, the Service Denial letter must be signed and witnessed by two people. Witness names and signatures can be placed in the available space below the member signature line. Witnesses must be 18 years of age or older and must write their relationship to the member or their title (if a facility employee) next to their signature. The documentation should accompany the facility's copy of the unsigned Service Denial letter and include where and when the letter was sent.

Tracking a Service Denial Letter

The facility is responsible for documenting all activities relating to Service Denial letters. In particular, please ensure that signed copies are returned to the facility and submitted to HMSA.

Mailing an unsigned Service Denial letter

When the member refuses to sign, or if the member cannot sign and does not have an authorized representative, the facility must send the unsigned Service Denial letter to the member's home (or address on record) within 24 hours of discharge (not including weekends and holidays). Telephonic notification of issuance of the Service Denial letter is required prior to mailing and must be documented on the letter. The unsigned Service Denial letter must be sent via certified mail on the same day as telephonic notification. Facilities must be able to demonstrate that they have sent the notification and have made a good-faith effort to obtain the member's signature and to follow up as necessary.

Certified mail receipts, along with the facility's copy of the Service Denial letter, must be kept in the member's medical records file. The facility is responsible for ensuring that signed copies are 1) returned to the facility and 2) submitted to HMSA.

Appealing a Service Denial Letter

Member options

If the member disagrees with the Service Denial decision, the member may request an expedited (72-hour) appeal if the member's health or ability to function could be harmed by waiting for a standard (60-day) appeal. If the member does not specifically request or qualify for an expedited appeal, he or she may request a standard appeal within 30 days of the date of the Service Denial letter. Detailed information about the appeals process is included on the actual Service Denial letter.

HMSA response to appeals

HMSA will respond to requests for expedited appeals within 72 hours. An extension of up to 10 extra working days is permitted if the member needs time to provide additional information or if HMSA needs additional diagnostic tests to be completed. HMSA will respond to requests for standard appeals within 60 days.

Revision History