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menubarNorth Valley Hospital

North Valley Hospital

Message from Medicare

Your Rights While You Are a Medicare/Champus/Tricare Hospital Patient

  • You have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of your illness or injury. According to federal law, your discharge date must be determined solely by your medical needs, not by diagnosis-related groups (DRGs) or Medicare, Champus or Tricare payments.
  • You have the right to be fully informed about decisions affecting your Medicare/Champus/Tricare coverage and payment for your hospital stay and for any post-hospital services.
  • You have the right to request a review by a peer review organization (PRO) of any written notice of noncoverage that you receive from the hospital stating that Medicare/Champus/Tri-West will no longer pay for your hospital care. PROs are groups of doctors who are paid by the federal government to review medical necessity, appropriateness and quality of hospital treatment furnished to Medicare/Champus/Tri-West patients. The phone number and address of the PRO for our area is:
Medicare Patients
Mountain Pacific Quality Health Foundation
3404 Cooney Drive
Helena, MT 59602
(800) 497-8232
 
Champus/Tricare Patients
For medical-surgical care/service:
TriWest Healthcare Alliance Corp.
Attn: Reconsideration Unit
P.O. Box 42049
Phoenix, AZ 85080
(888) TriWest (874-9378)

For mental health and substance abuse care/service:
Merit Behavioral Care Corp.
Attn: Reconsideration Unit
P.O. Box 42150
Phoenix, AZ 85080
(888) TriWest (874-9378)

Talk to Your Doctor About Your Stay in the Hospital

You and your doctor know more about your condition and your health needs than anyone else. Decisions about your medical treatment should be made between you and your doctor. If you have any questions about your medical treatment, your need for continued hospital care, your discharge or your need for possible post-hospital care, don’t hesitate to ask your doctor. The hospital’s patient representative or social worker also will help you with your questions and concerns about hospital services.

If You Think You Are Being Asked to Leave the Hospital Too Soon

  • Ask a hospital representative for a written notice of explanation immediately, if you have not already received one. This notice is called a notice of noncoverage. You must have this notice of noncoverage if you wish to exercise your right to request a review by the PRO.
  • The notice of noncoverage will state either that your doctor or the PRO agrees with the hospital’s decision that Medicare/Champus/Tricare will no longer pay for your hospital care.
    • If the hospital and your doctor agree, the PRO does not review your case before a notice of noncoverage is issued. The PRO will respond to your request for a review of your notice of noncoverage and seek your opinion. You cannot be made to pay for your hospital care until the PRO makes its decision, if you request the review by noon of the first work day after you receive the notice of noncoverage.
    • If the hospital and your doctor disagree, the hospital may request the PRO to review your case. If it does make such a request, the hospital is required to send you a notice to that effect. In this situation the PRO must agree with the hospital or the hospital cannot issue a notice of noncoverage. You may request that the PRO reconsider your case after you receive a notice of noncoverage, but since the PRO has already reviewed your case once, you may have to pay for at least one day of hospital care before the PRO completes this reconsideration.
IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL THE COSTS OF YOUR STAY BEGINNING WITH THE THIRD DAY AFTER YOU RECEIVE THE NOTICE OF NONCOVERAGE. THE HOSPITAL, HOWEVER, CANNOT CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF NONCOVERAGE.

How to Request a Review of the Notice of Noncoverage

  • If the notice of noncoverage states that your physician agrees with the hospital’s decision:
    • You must make your request for review to the PRO by noon of the first work day after you receive the notice of noncoverage by contacting the PRO by phone or in writing.
    • The PRO must ask for your views about your case before making its decision. The PRO will inform you by phone and in writing of its decision of the review.
    • If the PRO agrees with the notice of noncoverage, you may be billed for all costs of your stay beginning at noon of the day after you receive the PRO’s decision.
    • Thus, you will not be responsible for the cost of hospital care before you receive the PRO’s decision.
  • If the notice of noncoverage states that the PRO agrees with the hospital’s decision:
    • You should make your request for reconsideration to the PRO immediately upon receipt of the notice of noncoverage by contacting the PRO by phone or in writing.
    • The PRO can take up to three working days from receipt of your request to complete the review. The PRO will inform you in writing of its decision on the review.
    • Since the PRO has already reviewed your case once, prior to issuing the notice of noncoverage, the hospital is permitted to begin billing you for the cost of your stay beginning with the third calendar day after you receive your notice of noncoverage even if the PRO has not completed its review.
    • Thus, if the PRO continues to agree with the notice of noncoverage, you may have to pay for at least one day of hospital care.

Note

The process described above is called “immediate review.” If you miss the deadline for this immediate review while you are in the hospital, you may still request a review of Medicare’s/Champus/Tricare decision to no longer pay for your care at any point during your hospital stay or after you leave the hospital. The notice of noncoverage tells you how to request this review.

Post-Hospital Care

When your doctor determines that you no longer need all the specialized services provided in a hospital, but you still require medical care, he or she may discharge you to a skilled nursing facility or home care. The discharge planner at the hospital will help arrange for the services you may need after your discharge. Medicare/Champus/Tricare and supplemental insurance policies have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will not be covered and how payment will be made. Consult with your doctor, hospital discharge planner, patient representative and your family in making preparations for care after you leave the hospital. Don’t hesitate to ask questions.