Notify Medicare Plus Blue^SM PPO members about their rights if post-acute care services will be terminated

Post-acute care facility providers, whether contracted or non-contracted, must notify Medicare Plus Blue^SM PPO members about their rights to appeal a decision regarding termination of post-acute care services. They must do this by complying with the requirements for the delivery of a valid Notice of Medicare Non-coverage (Form CMS 10123-NOMNC). Generally, this notice must be delivered to the member no later than two days before the termination of services.

Post-acute care facility providers include skilled nursing facilities, comprehensive outpatient rehabilitation facilities and home health agencies.

Upon receipt of a Notice of Medicare Non-Coverage, or NOMNC, members or their authorized representative have the right to an expedited appeal to a Centers for Medicare & Medicaid Services-delegated Quality Improvement Organization. In Michigan, KEPRO^® is the delegated QIO.

When a member appeals

If the member or the authorized representative appeals to the QIO, the provider will receive an Expedited Appeal Documentation Request from the QIO. The provider must:

• Deliver a valid Detailed Explanation of Non-Coverage to the member.
• Respond to the QIO’s Expedited Appeal Documentation Request.
• Submit supporting documentation within the timeframe set by the QIO.

Per CMS 100-04, Medicare Claims Processing Manual, Chapter 30, §260.3.6: “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.” Providers may not bill members for the balance of these services.

CMS forms and instructions
To access NOMNC and DENC forms and instructions, click here.