Notice of Non-Coverage Appeals
Medicare beneficiaries, whether receiving Fee-For-Service (FFS) benefits or those who are enrolled in a Medicare Advantage (MA) Organization, are entitled to an expedited review process when services from a skilled nursing facility (SNF), home health agency (HHA), comprehensive outpatient rehabilitation facility (CORF) or hospice will be terminated. The New Mexico Medical Review Association (NMMRA) has been contracted by the Centers for Medicare & Medicaid Services (CMS) to perform these appeal reviews.
Providers must deliver the Notice of Medicare Provider Non-Coverage (NONC) termination notice to the beneficiary (or legal authorized representative) no later than two days before the proposed termination of services. NMMRA will notify the provider when a beneficiary has requested an appeal. The provider must issue the Detailed Notice by close of business on the day that NMMRA notifies the provider of the beneficiary's request for an expedited appeal.
MA Beneficiaries
For MA beneficiaries, this notice is referred to as the Advance Notice (scroll down to Notices - MS Word under downloads). The language on the notice indicates that it is the MA organization that has determined that services are no longer necessary. The MA organization will get the notice to the provider to issue to the beneficiary or legal representative. The MA organization will write the Detailed Notice (scroll down to Notices - MS Word under downloads) for the provider to issue. Differences in the process include:
1. If the beneficiary or representative misses the deadline (noon before day of discharge) to request an expedited appeal, he/she will be referred to the MA organization to request reconsideration.
2. If NMMRA agrees with the discharge decision and the beneficiary or representative requests reconsideration, NMMRA will perform the review.
Services covered by MA organizations include SNF, HHA and CORF.
FFS Beneficiaries
For FFS beneficiaries, this notice is referred to as the Generic Notice (scroll down to Generic Notice in MS Word under downloads). The language on the notice indicates that it is the provider that has determined that services are no longer necessary. The provider will write and issue the Detailed Notice (scroll down to Detailed Notice in MS Word under downloads). Differences in the process include:
1. If the beneficiary or representative misses the deadline (noon before the day of discharge) to request an expedited appeal, NMMRA will accept the appeal, but it will not be expedited and the beneficiary is not protected from liability.
2. If the services being provided are from an HHA or CORF, the beneficiary or representative is required to obtain certification from a physician indicating that the beneficiary will be at significant risk if services are terminated before an expedited appeal is performed.
3. If NMMRA agrees with the discharge decision and the beneficiary or representative requests reconsideration, he/she will be given information about how to contact the CMS-contracted Qualified Independent Contractor (QIC).
SNFs are obligated to comply with notice requirements through the amendment of the Code of Federal Regulations (42CFR489.27(b)) provider agreement regulations, as well as through their contractual arrangements with MA organizations. Section 1819(h) of the Social Security Act specifies penalties that may be used by the Secretary of the Department of Health and Human Services (DHHS) when a SNF is not in substantial compliance with the requirements for participation in the Medicare program. These penalties are applied on the basis of surveys conducted by CMS or other survey agencies. In addition, the Code of Federal Regulations (42CFR488.406) includes other penalties for non-compliance, such as denials of payment and corrective action plans.
HHAs are obligated to comply with notice requirements through the amendment of the Code of Federal Regulations (42CFR489.27(b)) provider agreement regulations, as well as through their contractual arrangements with MA organizations. In addition, HHAs are regulated in part by conditions of participation found in the Code of Federal Regulations (42CFR484.12), which indicate that HHAs must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations.
CORFs will be obligated to comply with notice requirements through the amendment of the Code of Federal Regulations (42CFR489.27(b)) provider agreement regulations, as well as through their contractual arrangements with MA organizations.
MA organizations may choose to delegate the responsibility for discharge and termination decisions and the delivery of detailed notices in disputed termination cases to the SNF, HHA, or CORF. MA organizations also may offer incentives to CORFs for compliance with these responsibilities, or penalties for non-compliance, through their private contractual arrangements. However, consistent with the Code of Federal Regulations (42CFR422.502(i)), MA organizations remain ultimately responsible for such delegated requirements.
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