Care Denial Letter

A Care Denial letter informs Medicare members that Medicare will not provide HHA 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.

Issuing a Care Denial Letter

When a Care Denial Letter is Required

There are two situations when an HHA must issue a Care Denial letter, both of which require the same form. (Refer to Home Health Care Denial [PDF]).

• The member is denied home healthcare prior to receiving services.
• The member is no longer eligible for home healthcare and objects to the discontinuation of services.

Completing a Care Denial Letter

Please follow these general guidelines when completing a Care Denial letter:

• Fill in the attending physician's full name (e.g., John Q. Aloha, M.D.).
• Complete all blank fields on the letter. (If applicable, indicate date mailed.)
• Indicate the date that services are being discontinued, if applicable.
• Ensure that copies sent to HMSA are legible.

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

Send a copy of the completed Care Denial letter to:

HMSA – Medical Management Department
P.O. Box 2001
Honolulu, HI 96805
Fax: 808-944-5611

Obtaining Signatures

The Care Denial letter must be signed and dated if services are discontinued and the member objects to the discontinuation. A copy of the signed letter must be kept in the member's medical file.

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 confused or otherwise unable to sign the Care Denial letter, a legal representative, family member or relative may sign on the member's behalf. The legal representative, family member or relative must understand that signing the Care Denial letter does not indicate concurrence with the decision to deny care. Appeal options are available to the member, as described later in this section.

• Legal Representative: A legal representative may sign the Care 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 Care 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 Care 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 Care Denial letter and include where and when the letter was sent.

Distribution and Tracking

Distributing a Care Denial Letter

The HHA should give the original Care Denial letter to the member or member's authorized representative. Copies should be filed in the member's medical record or sent to:

• Member's attending physician
• HHA's business office
• HMSA's Medical Management Department (Fax: 808-944-5611)

Tracking a Care Denial Letter

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

Mailing an Unsigned Care 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 Care Denial letter to the member's home (or address on record) within 24 hours of discharge (not including weekends and holidays). The unsigned Care Denial letter must be hand delivered or sent via certified mail. 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 Care Denial letter, must be kept in the member's medical records file. The facility is responsible for ensuring that signed copies are returned to the facility and submitted to HMSA.

Appealing a Care Denial Letter

Member Options

If the member disagrees with the Care 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 Care Denial letter. Detailed information about the appeals process is included on the actual Care 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