HINN 12 continued-stay notice after QIO coverage determination
Prepare a continued-stay HINN 12 when an Original Medicare beneficiary chooses to remain in the hospital beyond the coverage end established by the actual BFCC-QIO determination. Reconcile discharge notices and professionally supplied reason, liability date and estimate; no coverage or collection right is decided.
Keep notices, patient identifiers, dates of individual care, signatures and clinical explanations only in your secure case system. This workspace stores categorical research inputs and checklist progress.
Sources and scope
Official CMS source — HINN archive: HINN-12-Instructionsv508.pdf full2pages andModel-HINN-12-v508.pdf onepage; rawarchivehash andentrylocators · checked 2026-10-16
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This checklist does not complete, sign or deliver a notice. No individual deadline, charge, clinical reason or patient choice is generated.