(Medicare Claims Processing Manual)

When a beneficiary transfers to another provider at the same level of care (e.g., a beneficiary transfers from one SNF to another while remaining in a Medicare -covered SNF stay).   When a provider discontinues care for business reasons (e.g., an HHA refuses to continue care at a home with a dangerous animal or because the beneficiary was receiving physical therapy and the providers physical therapist leaves the HHA for another job).  260.3 - Notice of Medicare Non -Coverage  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The notice is subject to the Paperwork Reduction Act Process and approval by the Office of Management and Budget.  OMB -approved notices may only be modified as per their accompanying instructions.  Unapproved modifications may invalidate the NOMNC. The notice and accompanying instructions may be found online at http://www.cms.gov/Medicare/Medicare -General -Information/BNI   260.3.1 - Alterations to the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The NOMNC must remain two pages.  The notice can be two sides of one page or one side of two separate pages, but must not  be condensed to one page.   Providers may include their business logo and contact information on the top of the NOMNC. Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, etc.   Providers may include information in the optional Additional Information section relevant to the beneficiarys situation.   Note:  Including information normally included in the Detailed Explanation of Non-Coverage (DENC) in the Additional Information section does not satisfy a providers responsibility to deliver the DENC, if otherwise required.  260.3.2 - Completing the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  Providers must use the OMB -approved NOMNC (CMS -10123).  Providers must type or write the following information in the corresponding blanks of the NOMNC:    Patient name   Medicare patient number   Type of coverage (SNF, Home Health, CORF, or Hospice)   Effective date (last day of coverage)   Note:  The effective date is always the last day beneficiaries will receive coverage for their services.  Beneficiaries have no liability for services received on this date, but may face charges for services received the day following the effective date of the N OMNC for home health, hospice, and CORF services.  Because SNFs cannot bill the beneficiary for services furnished on the day of (but before the actual moment of) discharge, beneficiaries may leave a SNF the day after the effective date and not face liabil ity for such services.   260.3.3  Provider Delivery of the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per 260.2.  A NOMNC must be delivered even if the beneficiary agrees with the termination of services.   Medicare providers are responsible for the delivery of the NOMNC.  Providers may formally delegate the delivery of the notices to a designated agent such as a courier service; however, all of the requirements of valid notice delivery apply to designated agents.   The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature.   Electronic issuance of NOMNCs is not prohibited. If a provider elects to issue a NOMNC that is viewed on an electronic screen before signing, the beneficiary must be given the option of requesting paper issuance over electronic if that is what is preferred. Regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary must be given a paper copy of the NOMNC, with the required beneficiary -specific information in serted, at the time of notice delivery.   260.3.4 - Required Delivery Timeframes  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The NOMNC should be delivered to the beneficiary at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.  For example, if the last day of covered SNF care is a Friday, the NOMNC should be delivered no later than the preceding Wednesday.   Note: The two day advance requirement is NOT a 48 hour requirement.  For example, if a patients last covered home health service is at 10AM on Wednesday and the notice is delivered at 4PM on the prior Monday, it is considered timely.   If home health services are being provided less frequently than daily, the notice must be delivered no later than the next to last visit before Medicare covered services end.  For example, if home health care is provided on Tuesdays and Thursdays, and Tues day is the last day of Medicare covered services, the notice must be delivered no later than the preceding Thursday.   The NOMNC may be delivered earlier than two days preceding the end of covered services.  However, delivery of the notice should be closely tied to the impending end of coverage so a beneficiary will more likely understand and retain the information regardi ng the right to an expedited determination.  The notice may not be routinely given at the time services begin.  An exception is when the services are expected to last fewer than two days.  In these instances, the notice may be given by the provider when services begin.   There is an accepted circumstance when the NOMNC may be delivered sooner than two days or the next to last visit before coverage ends.  This exception is limited to cases where a beneficiary receiving home health services is found to no longer be homebound, and thus ineligible for covered home health care.  In this circumstance, the NOMNC should be immediately delivered to the beneficiary upon discovery of the loss of homebound status.  We expect that in the vast majority of cases, in all settings, the decision of a physician to end care will be based on medical necessity, and thus, foreseeable by the provider within the required time frames for notice delivery.  260.3.5 - Refusal to Sign the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If the beneficiary refuses to sign the NOMNC the provider should annotate the notice to that effect, and indicate the date of refusal on the notice.  The date of refusal is considered to be the date of notice receipt.  Beneficiaries who refuse to sign the NOMNC remain entitled to an expedited determination.   260.3.6 - Financial Liability for Failure to Deliver a Valid NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If a Qualified Independent Contractor (QIO) determines that a provider did not deliver a valid NOMNC to a beneficiary, the provider is financially liable for continued services until two days after the beneficiary receives valid notice, or until the effective date of the valid notice, whichever is later.   260.3.7 - Amending the Date of the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If the initial NOMNC was delivered to a beneficiary and the effective date was changed, the provider may amend the notice to reflect the new date. The newer effective date may not be earlier than the effective date of the original notice except in those ca ses involving the abrupt end of services, as discussed in 260.3.4.  The beneficiary must be verbally notified as soon as possible after the provider is aware of the change.  The amended NOMNC must be delivered or mailed to the beneficiary and a copy retained in the beneficiarys file.   If an expedited determination is already in progress, the provider must immediately notify the QIO of the change and provide an amended notice to the QIO.   260.3.8  NOMNC Delivery to Representatives  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The NOMNC may be delivered to a beneficiarys appointed or authorized representative.  Appointed representatives are individuals designated by beneficiaries to act on their behalf during the appeal process.  A beneficiary may designate an appointed representative via the Appointment of Representative form, the CMS -1696.  http://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/downloads/cms1696.pdf    See Chapter 29 of the Medicare Claims Processing Manual, section 270.1, for more information on appointed representatives.   CMS usually requires that notification to a beneficiary who has been deemed legally incompetent be made to an authorized representative of the beneficiary. Generally, an authorized representative is an individual who, under State or other applicable law, m ay make health care decisions on a beneficiarys behalf (e.g., the beneficiarys legal guardian, or someone appointed in accordance with a properly executed durable medical power of attorney).   However, if a beneficiary is temporarily incapacitated a person (typically, a family member or close friend) whom the provider has determined could reasonable represent the beneficiary, but who has not been named in any legally binding document, may be a representative for the purpose of receiving the notices described in this section. Such a representative should have the beneficiarys best interests at heart and must act in a manner that is protective of the beneficiary and the beneficiarys rights. There fore, a representative should have no relevant conflict of interest with the beneficiary.  In these instances of delivering a notice to an unnamed representative, the provider should annotate the NOMNC with the name of the staff person initiating the contact, the name of the person contacted, and the date, time, and method (in person or telephone) of the contact. A copy of the NOMNC with this information should be retained in the beneficiarys record.   Note -  Exceptions to in person notice delivery.  If the NOMNC must be delivered to a representative not living with the beneficiary, the provider is not required to make off -site in- person notice delivery to the representative.  The provider must complete  the NOMNC as required and telephone the representative at least two days prior to the end of covered services.  The provider should inform the representative of the beneficiarys right to appeal a coverage termination decision.   The information provided should include the following:    The beneficiarys last day of covered services, and the date when the beneficiarys liability is expected to begin.    The beneficiarys right to appeal a coverage termination decision.   A description of how to request an appeal by a QIO.   The deadline to request a review as well as what to do if the deadline is missed.    The telephone number of the QIO to request the appeal.   The date the provider communicates this information to the representative, whether by telephone or in writing, is considered the receipt date of the NOMNC.  The NOMNC must be annotated with the following information on the day that the provider makes telephone contact:   Reflect that all of the information indicated above was communicated to the representative;   Note the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.   A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiarys medical file.   If the provider chooses to communicate the information in writing, a hard copy of the NOMNC must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g. FedEx, UPS) The burden is on the provider to demonstrate that timely contact was attempted with the representative and that the notice was delivered.   The date that someone at the representatives address signs (or refuses to sign) the receipt is considered the date received. Place a copy of the annotated NOMNC in the beneficiarys medical file.   If both the provider and the representative agree, providers may send the notice by fax or e-mail, however, providers fax and e -mail systems must meet the The Health Insurance Portability and Accountability Act of 1996 ( HIPAA) privacy and security requirements.   260.3.9 - Notice Retention for the NOMNC  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The provider must retain the original signed NOMNC in the beneficiarys file.  The beneficiary should receive a paper copy of the NOMNC that includes all of the required information such as the effective date and covered service at issue.  Electronic notice retention is permitted if the NOMNC was delivered electronically.   260.3.10 - Hours of NOMNC Delivery  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)