Currentpriority healthPolicy N/A

Notice of Medicare Non-Coverage (NOMNC) form

This document is Priority Health's Notice of Medicare Non-Coverage form and instructions for beneficiaries whose Medicare coverage for specified services is ending. It explains appeal rights, how to request an immediate (timely) appeal through the Quality Improvement Organization (QIO), and patient acknowledgement.

Policy Summary

Payerpriority health

PolicyNotice of Medicare Non-Coverage (NOMNC) form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and provide the Notice of Medicare Non-Coverage form with the coverage end date, service type, QIO contact information, and the patient or representative signature acknowledging receipt and understanding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Noon beforeappeal deadline

2 daysindependent review decision timeline

1-800-MEDICAREpatient help line

Policy Snapshot

This document is Priority Health's Notice of Medicare Non-Coverage (NOMNC) form and instructions for beneficiaries whose Medicare coverage for specified services is ending. It explains the beneficiary's right to an independent medical review and that services will continue during an appeal, how to request an immediate (timely) appeal through the Quality Improvement Organization (QIO), the information the notice must include (coverage end date, type of service, QIO contact, and patient signature), and the patient's acknowledgement of receipt. The form is CURRENT and includes the required fields for patient name and number, coverage end date, service description, QIO contact information, and signature.

Form fields and placeholders

QIO_contactPlaceholders for QIO name and toll-free number

coverage_end_dateMedicare Coverage of Your Current Services Will End on [insert effective date]

patient_namePatient name field present

patient_numberPatient number field present

Policy Summary

Payerpriority health

PolicyNotice of Medicare Non-Coverage (NOMNC) form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Key Points on the Notice of Medicare Non-Coverage

Notice text highlights

Services continueServices will continue during an appeal.

Reviewer processIndependent reviewer will review medical records and may ask for patient's opinion.

Financial liability if upheldIf the reviewer agrees coverage should end, Medicare and the plan will not pay after the notice date.

Avoid financial liabilityStopping services by the date avoids financial liability.

Accessibility and nondiscriminationRight to accessible formats and nondiscrimination contact information provided.

Thresholds

Timely appeal cutoffNoon of the day before the Medicare coverage end date on the notice

Required Actions for Providers

Documentation Required

Provide completed NOMNC to patient

Complete and give the Notice of Medicare Non-Coverage form showing the date Medicare coverage will end, the type of service, QIO contact information, and obtain patient or representative signature acknowledging receipt and understanding.

Documentation Required

Include QIO contact information

Insert the appropriate QIO name and toll-free number on the notice so the beneficiary knows where to request an immediate appeal.

Denial Risk

Inform patient financial liability if coverage ends

Advise the beneficiary that if the independent reviewer upholds the decision to end coverage, Medicare and the plan will not pay for services after the date on the notice and the patient may be financially responsible for services received after that date.

Prior Authorization

Appeal initiation

Advise patients they must request a timely appeal from the QIO (no later than noon the day before the coverage end date) to obtain an immediate independent medical review and continuation of services during the appeal.

Timely appeal cutoff: Noon of the day before the Medicare coverage end date on the notice

NOMNC Form Fields & Placeholders

Field	Placeholder / Notes
{"text":"QIO_contact","status":""},{"text":"Placeholders for QIO name and toll-free number","status":""}
{"text":"additional_information","status":""},{"text":"Optional additional information field","status":""}
{"text":"coverage_end_date","status":""},{"text":"Medicare Coverage of Your Current Services Will End on [insert effective date]","status":""}
{"text":"patient_name","status":""},{"text":"Patient name field present","status":""}
{"text":"patient_number","status":""},{"text":"Patient number field present","status":""}
{"text":"service_description","status":""},{"text":"Insert type of services (free-text)","status":""}
{"text":"signature","status":""},{"text":"Signature of Patient or Representative and Date","status":""}

OpenPayer

Notice of Medicare Non-Coverage (NOMNC) form

Policy Snapshot

Key Points on the Notice of Medicare Non-Coverage

Required Actions for Providers

Defined Terms

NOMNC Form Fields & Placeholders

Policy Updates

Notice of Medicare Non-Coverage (NOMNC) form

Policy Snapshot

Key Points on the Notice of Medicare Non-Coverage

Required Actions for Providers

Defined Terms

NOMNC Form Fields & Placeholders

Also See

Policy Updates