Notices of Medicare Non-Coverage:
Getting it Right the First Time
Kristin Lueschow, RN, RRT, WCC, BAHA
Nurse Consultant
MetaStar, Inc.
Jenny White, RN
Medicare Lead/Nurse Consultant
MetaStar, Inc.
Objectives
Identify the correct CMS required notices
Review the timing and delivery
requirements of CMS notices
Review the expedited process and provider
responsibilities
Review the CMS website resources
Who is MetaStar?
An independent, not-for-profit organization
Mission: to effect positive change in the
quality, efficiency and effectiveness of
health care
Contract with Centers for Medicare and
Medicaid Services (CMS) as the Medicare
Quality Improvement Organization (QIO)
for Wisconsin
Medicare Coverage
Beneficiary’s Medicare coverage may be:
Original Medicare Coverage
Fee-for-service (FFS)
Notice of Medicare Provider Non-Coverage
(NOMPNC)
Medicare Advantage Plan
Notice of Medicare Non-Coverage (NOMNC)
Medicare Advantage
Notice of Non-coverage History
Grijalva v. Shalala: 1993 class action
lawsuit brought by beneficiaries enrolled in
the Medicare risk-based managed care
organization program
Challenged the adequacy of the managed
care appeals process
Medicare Advantage
Notice of Non-coverage History (Cont.)
Settlement agreement approved by the Arizona
District Court on December 4, 2000
Under the settlement agreement, the Centers for
Medicare & Medicaid Services (CMS) agreed to
publish a notice of proposed rulemaking proposing
regulations that would establish new notices and
appeals procedures when a MA organization
decides to terminate coverage or provide services
to an enrollee
Medicare Advantage
Notice of Non-coverage History (Cont.)
Key element to agreement was that CMS
would propose to establish an independent
review entity to conduct fast-track reviews
of appeals of decisions to terminate services
Medicare Advantage Notice History
CMS determined QIOs would conduct these
reviews because they had the necessary
health care reviewers to make the medical
necessity decisions
QIOs have extensive experience with this
type of review process
Medicare Advantage Notice History (Cont.)
Medicare Advantage enrollees receive a Notice of
Medicare Non-Coverage (NOMNC) prior to
termination of Medicare-covered
skilled nursing facility (SNF)
home health (HH)
comprehensive outpatient rehabilitation facility
(CORF) services
The NOMNC informs individuals of their right to
an immediate, independent review of the proposed
discontinuation of services
Medicare Advantage Enrollees Rights
MA enrollees have the right to request a
QIO fast-track review to appeal the MA
organization’s decision to terminate
coverage of Medicare covered services
FFS Notice of Non-coverage History
Original, fee for service Medicare
beneficiaries were given the same appeal
rights
the Benefits Improvement and Protection Act
(BIPA) §521 was passed November 2004
FFS Notice of Non-coverage History
As of July 1, 2005,
Home Health Agencies (HHAs)
Skilled Nursing Facilities (SNFs)
Comprehensive Outpatient Rehabilitation Facilities
(CORFs)
Hospice providers
are required to notify beneficiaries of their right to
a new expedited review process when these
providers anticipate that Medicare coverage of
their services will end
Identifying the Correct Notice to Issue
The provider must determine which
Notice of Non-coverage to issue based on
the beneficiary’s Medicare coverage:
FFS: Notice of Medicare Provider Noncoverage (NOMPNC)
MA: Notice of Medicare Non-coverage
(NOMNC)
Fee for Service
Notice of Medicare Provider Non-coverage
OMB Approval number 0938-0953
Form number CMS-10123
Expiration date 07/31/2011
Also called a generic notice
Medicare Advantage
Notice of Medicare Non-coverage
OMB approval number 0938-0910
Form No. CMS-10095
Expiration Date 08/31/2010
Also called an Advance Notice
When to Issue a Notice of Non-coverage
When all covered Medicare Part A services
are ending
When all Medicare Part B services are
ending
When a Notice of Non-coverage
Should NOT be Issued
When the beneficiary has exhausted
Medicare benefit days
When the beneficiary is transferring to a
higher level of care (hospital)
When the beneficiary is transferring to
another SNF
When the beneficiary decides to leave
Issuing a Valid Notice
Must use the appropriate CMS approved, standardized
form
Providers may not deviate from the content of the form except
where indicated
Minimum 12 point font
The name, address, and telephone number of plan or
provider that actually delivers the notice required at top of
the notice
Enrollee’s name
Patient ID number (no protected health information)
Issuing a Valid Notice (Cont.)
Must be issued at least two days prior to the
effective date
Type of service ending must be entered
i.e., skilled nursing services or Medicare Part B
services
Valid delivery to beneficiary or
representative
Valid Delivery
The beneficiary must be able to understand
the purpose and contents of the notice in
order to sign for receipt of it
If the beneficiary is not able to comprehend
the contents of the notice, it must be
delivered to and signed by a representative
If refuses to sign, document refusal on the
notice with date, time and staff signature
Valid Delivery (Cont.)
Telephone notification must include
Effective date and financial liability
Appeal rights and MetaStar’s telephone number
Deadline for the appeal
Confirm conversation by mailing written notice
Document on the notice date and time of verbal
notification, appeal rights explained, and
MetaStar’s telephone number was provided
Valid Delivery (Cont.)
Unable to make phone contact
Mail notice to representative by certified mail,
return receipt requested
Date someone signs at address (or refuses to
sign) is date of receipt
If the notice is returned by the post office with
no indication of refusal date, the beneficiary
liability starts on the second working day after
the providers mailing date
CMS Website
Beneficiary Notices Initiative (BNI)
www.cms.hhs.gov/bni
FFS ED notices and instructions
MA ED notices and instructions
FFS questions and answers
MetaStar’s Availability for Appeals
Accepts patient requests for notice of noncoverage appeals 24 hours/day
Performs appeal reviews 7 days/week
during normal business hours
Voice mail after hours
Health Insight on weekends
Appeal Process
Beneficiary or representative must call
MetaStar by noon the day before the
effective date
FFS appeal requests received after noon
will be processed but considered untimely
MA appeal requests received after noon will
be referred to the MA plan
Appeal Process:
MetaStar’s Responsibilities
Obtain comments from the beneficiary or representative,
provider, MA plan (if applicable) and physician (if FFS)
Provider must fax the Generic/Advance notice
immediately
MetaStar will validate the notice
If valid, MetaStar will request the medical record from the
provider
If invalid, MetaStar will notify the provider with instructions on
how to proceed
What makes a notice invalid?
Requirements of timing were not followed
Lack of OMB approval number
Notice was not issued to an appropriate representative
Method of delivery was incorrect ( i.e., left a voicemail
without mailing)
Provider did not retain a copy of the notice; however, if the
beneficiary /representative can produce the notice,
MetaStar will proceed with the process
What makes a notice invalid? (Cont.)
CMS approved form is not used (i.e., a FFS
beneficiary receives an MA notice)
Parts of the language of the notice are
missing
Notice is not signed and there is no
reference to delivery
Incorrect or missing expiration date
Invalid Notice Process
If the notice is determined to be invalid, a
new notice must be reissued
MA: reissue new notice with new effective date
FFS: reissue new notice with same effective
date and asterisk
See the www.cms.hhs.gov/bni, Revised Expedited
Determination Q&A’s as of March 2006, page 26,
question 13
Appeal Process:
Provider’s Responsibilities
Issue a Detailed Explanation of Non-coverage
(DENC) to the beneficiary/representative
Provide beneficiary specific comments
Fax the DENC and the medical record to MetaStar
within the required timeframes (usually within 24
hours)
Must have non-business day process and contacts
established
Detailed Explanation of Non-coverage
(DENC)
Provider must issue a DENC to beneficiary/representative
no later than close of business day of MetaStar’s
notification of an appeal request
Standardized CMS notice must be used
FFS: Form number CMS-10124
MA: Form number CMS-10095
The name, address, and telephone number of plan or
provider that actually delivers the notice required at top of
the notice
MA plans often complete their own and fax to the QIO
Detailed Explanation of Non-coverage (Cont.)
Must include:
the date it is issued
Beneficiary’s name
Patient ID number (no PHI)
Type of Medicare covered service
Beneficiary specific facts used to make the
decision
Expedited Determination Timelines
MetaStar will make a determination
FFS appeal: within 72 hours of a timely
request
MA: 24 hours of receiving the medical record
Beneficiary/beneficiary representative,
provider, physician and MA plan, if
applicable, will be notified by phone,
followed by a written notice
Beneficiary Financial Liability
If MetaStar agrees with the Notice of
Non-coverage, the beneficiary is liable for
costs starting the day after the effective date
If MetaStar disagrees with the Notice of
Non-coverage
Medicare covered services continue
The beneficiary is not liable for continued
services (except for coinsurance and
deductibles)
Reconsiderations
Beneficiary/representative has the right to a
second review when MetaStar agrees with
the Notice of Non-coverage
Same medical record documentation is used
FFS Reconsiderations
Maximus, a Qualified Independent
Contractor (QIC), performs the review
Beneficiary/representative must call the
QIC by noon the next day following verbal
notification
MA Reconsiderations
MetaStar performs the MA reconsiderations
Beneficiary/representative must contact MetaStar
by telephone or in writing no later than 60
calendar days from the date of MetaStar’s
determination letter
Different physician reviewer
Reconsiderations are completed within 14 days.
Beneficiary/beneficiary representative, provider,
and MA plan are notified of determination by
phone, followed by a written notice
Reconsideration
Beneficiary Financial Liability
If MetaStar or the QIC upholds the original
determination, the beneficiary is liable for
costs starting the day after the effective date
If MetaStar or the QIC overturn the original
determination, the beneficiary is not liable
for further services (except for coinsurance
and deductibles)
Questions?
Contact Information:
MetaStar, Inc.
2909 Landmark Place
Madison, WI 53713
Jenny White, RN,
(608) 274-1940 or (800) 362-2320 Ext. 8261
Kristin Lueschow, RN, RRT, WCC, BAHA
(608) 274-1940 or (800) 362-2320 Ext. 8295
www.metastar.com
This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. 9SOW-WI-BENP-10-04
.