The Notice of Medicare Non-coverage (NOMNC) is a standardized document designed to inform beneficiaries when a provider decides a service is no longer covered by Medicare. Understanding this notice is crucial for a beneficiary to protect their rights. The NOMNC is not a final denial of benefits, but an official warning that allows the recipient to take immediate action if they disagree with the provider’s decision.
Decoding the Notice of Medicare Non-coverage
The Notice of Medicare Non-coverage (Form CMS-10123) is a formal notification that a provider believes Medicare will soon cease paying for a beneficiary’s services. This document is required before coverage ends to prevent beneficiaries from being surprised by unexpected billing. The NOMNC is distinct from other forms, like the Advance Beneficiary Notice of Non-coverage (ABN), as its purpose is to inform of a pending termination of a previously covered service.
The notice clearly states the specific date when Medicare coverage for the service is expected to end, which is called the effective date of termination. It also includes the name and contact information for the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). The form also explicitly informs the beneficiary of their right to an immediate, independent medical review, which is an expedited appeal. A signature from the beneficiary or their representative is required to show they received and understood the notice, though refusing to sign does not negate the notice or the right to appeal.
Settings and Timing for Receiving the Notice
The NOMNC must be issued to beneficiaries receiving covered skilled services in specific institutional settings covered by Medicare Part A or Part B. These settings include:
- Skilled Nursing Facilities (SNFs)
- Home Health Agencies (HHAs)
- Comprehensive Outpatient Rehabilitation Facilities (CORFs)
- Hospice services
The timing of the notice is strictly regulated to allow the beneficiary time to respond and initiate an appeal. Providers must deliver the NOMNC at least two calendar days before the effective date that Medicare-covered services are scheduled to end. If a service is not provided daily, the notice must be given no later than the second-to-last day of service. This is a “calendar day” rule, and the timeframe is designed to provide sufficient opportunity for the patient to make an informed decision or request an expedited review.
Initiating the Expedited Review Process
A beneficiary who disagrees with the termination of their services has the right to request an immediate, expedited review, also called a fast appeal, from the BFCC-QIO. Initiating this process is the most effective action a beneficiary can take to dispute the provider’s decision to stop coverage. The NOMNC contains the necessary contact information, including the QIO’s toll-free number, to begin this process.
The deadline for requesting this review is strict: the beneficiary must contact the QIO no later than noon of the day before the effective date of termination listed on the NOMNC. If the beneficiary contacts the QIO by this deadline, Medicare requires the provider to continue furnishing the services while the appeal is pending. This continuation of services prevents a gap in care while the QIO reviews the case.
Once the QIO is contacted, they notify the provider, who is then required to deliver a Detailed Explanation of Non-Coverage (DENC) to the beneficiary by the close of business that same day. The DENC provides a more specific, medical-based reason for the termination decision, which the QIO uses to conduct its review. The QIO typically issues its determination within 72 hours of receiving the appeal request and all necessary information, though this timeline can vary slightly depending on whether the beneficiary is in Original Medicare or a Medicare Advantage plan.
Understanding Financial Liability
The financial implications of the NOMNC become a concern once the effective date of termination passes or if the expedited appeal is unsuccessful. If the beneficiary chooses to continue receiving the services after the date listed on the notice without a successful appeal, they become personally and financially responsible for the cost. The NOMNC serves as the official notice that Medicare will likely no longer cover these services, effectively transferring the financial risk to the beneficiary.
If the beneficiary initiates the expedited appeal but the QIO upholds the provider’s decision to terminate services, the beneficiary’s protection from financial liability generally ends on the date the QIO issues its determination. Providers are prohibited from billing the beneficiary for disputed services until the expedited determination process has been completed. If the beneficiary decides to continue receiving services after an unsuccessful appeal, they must be given an Additional Notice of Right to Appeal (ANORA) if they wish to pursue further appeal levels, but they must also acknowledge their personal financial responsibility.