Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As a continuation of the last blog post, here are further details around the clarification of requirements for administering the Notice of Medicare Non-Coverage (NOMNC) and the Advance Beneficiary Notice of Non-Coverage (SNFABN)
- The Notice of Medicare Non-Coverage (NOMNC) (Generic Notice) (CMS Form 10123)
Give any time the facility believes Medicare will no longer pay for skilled services.
- The Notice of Medicare Non-Coverage (NOMNC), sometimes referred to as the “Generic Notice”, is a component of the fee-for-service expedited determination process.
- This notice is to be given to all Medicare beneficiaries receiving Medicare Part A services, Medicare Part B services as well as Medicare Advantage Plan enrollees when coverage is terminated, regardless of whether the resident is remaining in the facility or being discharged.
- The “Generic Notice” should be delivered no later than two days before the date of the end of coverage. Through this expedited determination process, beneficiaries may obtain a QIO review to appeal a provider’s decision to end all their covered care for medical necessity reasons.
- The expedited determination regulations lay out a review process involving beneficiaries, providers, QIOs and other entities. Providers must give the “generic” notice to each beneficiary no later than two days before the end of all covered care, even if the beneficiary agrees with the discontinuation of coverage.
- The notice used is the OMB-approved CMS Form 10123, completed by the provider and signed by the beneficiary, and assures the beneficiary has been properly informed of the determination that covered care is ending and of their right to contest this decision. If the beneficiary accepts the provider’s determination, no additional action is required.
- In situations where the beneficiary disagrees, the beneficiary initiates an appeal by contacting the QIO utilizing the contact information obtained from the “generic notice”. The QIO is then responsible for establishing contact with the provider “immediately” to notify them of the appeal and request medical record documentation to assist in reviewing the coverage determination.
- Upon receipt of this notification, the provider must then give the beneficiary a second, more “detailed,” notice explaining the reason for the termination of coverage and outlining the specific regulation used by the provider to support this decision. The detailed notice is also an OMB-approved notice, specifically, the CMS Form 10124. This notice does not need to be signed by the beneficiary, but it must be submitted to the QIO with the requested medical records no later than close of business on the date the request is made.
- Using these records, the QIO decides on coverage and informs the involved parties. The review generally takes 72 hours. An “untimely” process also exists. If the beneficiary is not satisfied with the determination made by the QIO they may request reconsideration to the QIC using the process outlined in the QIO’s decision letter. Standard claim appeal rights still apply to these claims.
The next blog post, Part IV of V, provides further details around the clarification of requirements for administering the Advance Beneficiary Notice of Non-Coverage (SNFABN).
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