(Medicare Claims Processing Manual)

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)  Notice delivery should occur within the normal operating hours of the provider.  Providers are not expected to extend their hours or days of business solely to meet the requirements of the expedited determination process.  However, it is expected that all notices be provided as timely as possible within these constraints.   260.4 - Expedited Determination Process  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  260.4.1 - Beneficiary Responsibilities  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  260.4.1.1 - Timeframe for Requesting an Expedited Determination  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  A beneficiary who receives a NOMNC and disagrees with the termination of services may request an expedited determination by the appropriate QIO for the state where the services were provided.  The beneficiary must contact the QIO by noon of the day before the effective date on the NOMNC.  The beneficiary may contact the QIO by telephone or in writing.  If the QIO is unable to accept the request, the beneficiary must submit the request by noon of the next day the QIO is available.  260.4.1.2 - Provide Information to QIO  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The beneficiary must be available to answer questions or supply information requested by the QIO.  The beneficiary may, but is not required to, supply additional information to the QIO that he or she believes is pertinent to the case.   260.4.1.3 - Obtain Physician Certification of Risk (Home Health and CORF services only)  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  A beneficiary must obtain a physician certification stating that failure to continue home health or CORF services is likely to place the beneficiarys health at significant risk.  Without such a certification statement a QIO may not make a determination for service terminations in these settings.  The physician certification is a written statement from any licensed physician contacted by a beneficiary. This is a special certification required only in this expedited determination process for expedited determinations in home health and CORF settings.  A beneficiary may request an expedited determination from a QIO before obtaining this certification of risk.  Once the QIO is aware of a review request, it will instruct the beneficiary on how to obtain the necessary certification from a physician.   260.4.2 - Beneficiary Liability During QIO Review  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  A provider may not bill a beneficiary who has timely filed an expedited determination for disputed services until the review process, including a reconsideration by a Qualified Independent Contractor (QIC), if applicable, is complete.  260.4.3 - Untimely Requests for Review  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  If the beneficiary makes an untimely request to the QIO, the QIO will accept the request for review, but is not required to complete the review within its usual 72- hour deadline.  The QIO will make a determination as soon as possible upon receipt of the re quest.   Beneficiaries have up to 60 days from the effective date of the NOMNC to make an untimely request to a QIO.  When the beneficiary is still receiving services, the QIO must make a determination and notify the parties within 7 days of receipt of the request.  When the beneficiary is no longer receiving services, the QIO will make a determination within 30 days of the request.   The coverage protections discussed in 260.4.2 do not apply to a beneficiary who makes an untimely request to the QIO.   260.4.4 - Provider Responsibilities  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  When a provider is notified by a QIO of a beneficiary request for an expedited determination, the provider must:    Deliver the beneficiary a DENC (see 260.4.5) by close of business the day they are notified;    Supply the QIO with copies of the NOMNC and DENCs by close of business of the day of the QIO notification;    Supply all information, including medical records, requested by the QIO.  The QIO may allow this required information to be supplied via phone, writing, or electronically.   If supplied via phone, the provider must keep a written record of the information it provides within the patient record; and  Furnish the beneficiary, at their request, with access to or copies of any documentation it provides to the QIO.  The provider may charge the beneficiary a reasonable amount to cover the costs of duplicating and delivering the documentation.  This document ation must be provided to the beneficiary by close of business of the first day after the material is requested.   260.4.5 - The Detailed Explanation of Non -Coverage  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The DENC 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 DENC. The notice  and accompanying instructions may be found online at http://www.cms.gov/Medicare/Medicare -General -Information/BNI .  Medicare providers are responsible for the delivery of the DENC to beneficiaries who request an expedited determination by the QIO.  The DENC must contain the following information:    The facts specific to the beneficiarys discharge and providers determination that coverage should end.    A specific and detailed explanation of why services are either no longer reasonable and necessary or no longer covered.    A description of, and citations to, the Medicare coverage rule, instruction, or other policies applicable to the review.   The provider should make insertions on the notice in Spanish, if necessary.  If this is impossible, additional steps should be taken to ensure that the beneficiary comprehends the content of the notice.  Providers may resource CMS multilingual services provided through the 1- 800-MEDICARE help line if needed.  The delivery must occur in person by close of business of the day the QIO notifies the provider that the beneficiary has requested an expedited determination.  A provider may also choose to deliver the DENC with the NOMNC.   The DENC does not require a signature but should be annotated in the event of a beneficiarys refusal to accept the notice upon delivery.  Note:  An HHA is not required to make a separate trip to the beneficiarys residence solely to deliver a DENC.  Upon notification from the QIO of a beneficiarys request for an expedited determination, an HHA may telephone the beneficiary to provide the information contained on the DENC, annotate the DENC with the date and time of telephone contact and file with the beneficiarys records.  A hard copy of the DENC should be sent to the beneficiary via tracked mail or other personal courier method by close of  business of the day the QIO notifies the provider that the beneficiary has requested an expedited determination.  The burden is on the provider to demonstrate that timely contact was attempted with the beneficiary and that the notice was delivered.   DENC delivery to representatives, DENC hours of delivery, and DENC retention requirements are the same as the NOMNC requirements outlined in 260.3.   Expedited Determination Scenario in a Skilled Nursing Facility -  Example   On June 2nd, the SNF delivers a NOMNC to Bob Mills notifying him that his Medicare covered stay will end on June 4th.  Bob decides to request an expedited determination.   June 2nd  June 3nd June 4rd June 5th June 6th   NOMNC Delivered  Bob receives a NOMNC indicating that his coverage is ending June 4th.  Bob must request an expedited determination by noon today.  NOMNC Effective Date  This is the last day of coverage, as stated on the NOMNC.   If Bob made his request on June 2nd: The QIO makes its decision and notifies Bob and the SNF by COB.   If Bob made his request on  June 3rd: The QIO makes its decision and notifies Bob and the SNF by COB.   The QIO must notify the SNF of Bobs request for an expedited determination.   The SNF must deliver the DENC to Bob by COB today.  The SNF must provide relevant medical records to the QIO by COB today. The beneficiary has no liability for this day as this is the last day of coverage in the SNF.  If  QIO decision is unfavorable:  Beginning today Bob is liable for his stay if he does not leave the SNF.   260.5 - QIO Responsibilities  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  260.5.1 - Receive Beneficiary Requests for Expedited Review  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  QIOs must be available to receive beneficiary requests for review 24 hours a day, 7 days a week.   260.5.2 - Notify Providers and Allow Explanation of Why Covered Services Should End (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  When the QIO receives a request from a beneficiary, the QIO must immediately notify the provider of services that a request for an expedited determination was made.  If the request is received after normal working hours, the QIO should notify the provider as soon as possible on the morning after the request was made.   260.5.3 - Validate Delivery of NOMNC (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO must validate that the NOMNC included the required elements outlined below:    Date that coverage of services ends.    Date that beneficiarys financial liability begins.    Description of right to an expedited determination (and how to request an expedited determination) and the right to submit relevant information to the QIO.    Right to detailed information on why the provider believes Medicare will no longer cover services.    Contact information for QIO in the state where services were delivered.   The QIO should determine  that NOMNC delivery was valid if all of the following criteria are met:    All elements stated above are included.    The beneficiary signed and dated the notice.  If the NOMNC was annotated because the beneficiary refused to sign the notice upon delivery, the QIO may still conduct an expedited determination in these instances.   Notice was delivered  at least two days before services terminate.  For a non -residential provider, the notice may be delivered at the next to last visit before services terminate.   Invalidating a NOMNC should be a rare occurrence.  The only reasons to invalidate are the lack of one of the criteria stated above or a pattern of minor errors as established by the provider.