Patient Accounts will not send billing statements to you while Medicare is processing your claim. You are responsible for all non-covered items received while a patient; this includes Take Home Medications and Personal Comfort Items. If you were an outpatient, Medicare will not cover pharmacy items that could be Self-Administered. You are responsible for all deductibles and coinsurance amounts. You are responsible for promptly responding to Medicare inquiries. Patient Accounts provides billing services for Rapid City Emergency Services (the Emergency Department). You should receive the payment for this provider; please forward the payment and explanation of benefits to the Patient Accounts Department for credit on your account and for supplemental billing purposes.
AN IMPORTANT MESSAGE FROM MEDICARE (FOR ADMISSIONS TO PPS HOSPITALS)
YOUR RIGHTS WHILE YOU ARE A MEDICARE 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 medical needs, not by "Diagnosis Related Groups" (DRGs) or Medicare payments.
You have the right to be fully informed about decisions affecting your Medicare 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 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 patients. The phone number and address of the PRO for your area are:
South Dakota Foundation for Medical Care
1323 South Minnesota Ave. Sioux Falls, SD 57105 (605) 336-3505
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 will also 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 will no longer pay for your hospital care.
--If the hospital and your doctor agrees, the PRO does not review your case before a Notice of Noncoverage is issued. But 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 on the review.
--If the PRO agrees with the Notice of Noncoverage, you may be billed for all cost 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 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.
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 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.
Patient’s Certification, Authorization to Release information, and Payment Release. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician service to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.
Welcome to Rapid City Regional Hospital. During your stay as a patient here, there are several items and services which your Medicare insurance does not cover for payment. These include:
1. The difference in price between a private and a semiprivate room, when the reason for the private room is patient preference – you have requested a private room. If your medical condition warrants a private room, Medicare will cover the difference.
2. Personal comfort items which are used for personal hygiene, such as toothpaste, deodorant, soap, etc. 3. Pharmacy items that are prescription medication taken home from the hospital.
4. Plastic surgery performed for cosmetic purposes.
5. Dental work performed. Medicare requires Rapid City Regional Hospital to inform their Medicare patients in writing of these non-covered items. Medicare requires Medicare beneficiaries to acknowledge that they have been informed by the hospital by signing and dating the receipt listed below.
I have read the above and understand that I will be charged for personal comfort items and prescriptions for home use. I may be charged for the difference in price between a private and semi-private room. I also understand that I will be charged for plastic surgery performed for cosmetic purposes, or for dental work performed.
ACKNOWLEDGMENT OF RECEIPT
– My signature only acknowledges my receipt of this Message from Rapid City Regional Hospital on Tuesday, April 21, 2009 and does not waive any of my rights to request a review or make me liable for any payment.
Signature of beneficiary or person
Acting on behalf of beneficiary
Date of receipt