evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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).
(Medicare Claims Processing Manual)
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;
(Medicare Claims Processing Manual)
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)  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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.   If a QIO invalidates a NOMNC, a new NOMNC must be issued to the beneficiary with an effective date at least two days after the beneficiary receives valid notice.  If the beneficiary again disagrees with the termination of care, a new request to the QIO mus t be made.   260.5.4 - Solicit the Views of the Beneficiary  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)  The QIO must solicit the views of the beneficiary who requested the expedited determination.   260.5.5 - Solicit the Views of the Provider  (Rev. 2711, Issued: 05- 24-13, Effective: 08 -26-13, Implementation: 08- 26-13)