Notice of Medicare Noncoverage

Information taken from the CMS Web site www.cms.hhs.gov/healthplans/appeals.

As of January 1, 2004, enrollees of Medicare Advantage (MA) plans have the right to an expedited review by a Quality Improvement Organization (QIO) when they disagree with their MA plan’s decision that Medicare coverage of their services from a skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) should end. This new right stems originally from the Grijalva lawsuit and was established in regulations in a final rule published on April 4, 2003 (68 FR 16652). It is similar to the longstanding right of a Medicare beneficiary to request a QIO review of a discharge from an inpatient hospital.

Regulations

Based on the provisions of the April 2003 final rule, SNFs, HHAs, and CORFs must provide an advance notice of Medicare coverage termination to MA enrollees no later than 2 days before coverage of their services will end. If the patient does not agree that covered services should end, the enrollee may request an expedited review of the case by the QIO in that state and the enrollee’s MA plan must furnish a detailed notice explaining why services are no longer necessary or covered. The review process generally will be completed within less than 48 hours of the enrollee’s request for a review. The new SNF, HHA, and CORF notification and appeal requirements distribute responsibilities under the new procedures among four parties: 1) The MA organization, 2) The provider, 3) The patient/MA enrollee or authorized representative, and 4) the QIO.

Further Information

  • The Notice of Medicare Noncoverage (NOMNC) form fulfills the CMS requirement 42 CFR 422.624, 422.626, and 489.27, and Chapter 13 of the MA Manual for Medicare Advantage organizations effective January 1, 2004. This form can be found in the “Forms Library” in the Provider Section of www.securityhealth.org

Reminder

  • Security Health Plan’s care managers will attempt to work collaboratively with each provider to facilitate the advance notice process. However, it remains the agency/facility’s responsibility to issue the NOMNC in a valid manner. This is a federal requirement, and is not an optional procedure.
Last Updated on: 09-20-2011