OMB Approval No. 0938-0910 NOTICE OF MEDICARE NON-COVERAGE Patient Name: Patient ID Number: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED NURSING FACILITY SERVICES WILL END: {insert effective date} • • Your Medicare Advantage (MA) plan and/or provider have determined that Medicare probably will not pay for your current SKILLED NURSING FACILITY services after the effective date indicated above. You may have to pay for any SKILLLED NURSING FACILITY services you receive after the above date. YOUR RIGHT TO APPEAL THIS DECISION • You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services. • If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer will also look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. • If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal. • If you choose to appeal, and the independent reviewer agrees that services should no longer be covered after the effective date indicated above, neither Medicare nor your MA plan will pay for these services after that date. • If you stop services no later than the effective date indicated above, you will avoid financial liability. HOW TO ASK FOR AN IMMEDIATE APPEAL • • You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. See the next page for more information • • The QIO will notify you of its decision as soon as possible, generally by no later than the effective date of this notice. Call your QIO at: Quality Insights of Pennsylvania 2601 Market Place Street, Suite 320 Harrisburg, PA 17110 1-800-322-1914 to appeal, or if you have questions. OTHER APPEAL RIGHTS: • If you miss the deadline for requesting an immediate appeal with the QIO, you still may request an expedited appeal from your MA plan. If your request does not meet the criteria for an expedited review, your MA plan will review the decision under its rules for standard appeals. Please see your Evidence of Coverage for more information. • Contact your MA plan or 1-800-MEDICARE (1-800-633-4227), or TTY/TDD: 1-877486-2048 for more information about the MA appeals process. ADDITIONAL INFORMATION (OPTIONAL) Contact your health plan at Highmark Blue Shield/FreedomBlue Medicare Advantage Healthcare Management Services Appeal Department P.O. Box 535073 Pittsburgh, PA 15253-5073 FAX: Medicare Advantage Appeal Department 1-800-485-9610 Fax# 1-800-894-7947 TTY/TDD# 1-888-422-1226 If you have any questions you can contact your health plan at 1-866-306-1061 Monday through Friday, 8:00am-4:30pm. If you have a hearing or speech impairment, please call us at TTY/ TDD 1-800-988-0668 Monday through Friday, 8:00am-4:30pm. Please sign below to indicate that you have received this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. __________________________________________ Signature of Patient or Authorized Representative _____________ Date Form No. CMS-10095 Exp. Date 03/31/2007 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0910. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. OMB Approval No. 0938-0910 NOTICE OF MEDICARE NON-COVERAGE Patient Name: Patient ID Number: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT HOME HEALTH AGENCY SERVICES WILL END: {insert effective date} • • Your Medicare Advantage (MA) plan and/or provider have determined that Medicare probably will not pay for your current HOME HEALTH AGENCY services after the effective date indicated above. You may have to pay for any HOME HEALTH AGENCY services you receive after the above date. YOUR RIGHT TO APPEAL THIS DECISION • You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services. • If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer will also look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. • If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal. • If you choose to appeal, and the independent reviewer agrees that services should no longer be covered after the effective date indicated above, neither Medicare nor your MA plan will pay for these services after that date. • If you stop services no later than the effective date indicated above, you will avoid financial liability. HOW TO ASK FOR AN IMMEDIATE APPEAL • • You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. See the next page for more information • • The QIO will notify you of its decision as soon as possible, generally by no later than the effective date of this notice. Call your QIO at: Quality Insights of Pennsylvania 2601 Market Place Street, Suite 320 Harrisburg, PA 17110 1-800-322-1914 to appeal, or if you have questions. OTHER APPEAL RIGHTS: • If you miss the deadline for requesting an immediate appeal with the QIO, you still may request an expedited appeal from your MA plan. If your request does not meet the criteria for an expedited review, your MA plan will review the decision under its rules for standard appeals. Please see your Evidence of Coverage for more information. • Contact your MA plan or 1-800-MEDICARE (1-800-633-4227), or TTY/TDD: 1-877486-2048 for more information about the MA appeals process. ADDITIONAL INFORMATION (OPTIONAL) Contact your health plan at Highmark Blue Shield/FreedomBlue Medicare Advantage Healthcare Management Services Appeal Department P.O. Box 535073 Pittsburgh, PA 15253-5073 FAX: Medicare Advantage Appeal Department 1-800-485-9610 Fax# 1-800-894-7947 TTY/TDD# 1-888-422-1226 If you have any questions you can contact your health plan at 1-866-306-1061 Monday through Friday, 8:00am-4:30pm. If you have a hearing or speech impairment, please call us at TTY/ TDD 1-800-988-0668 Monday through Friday, 8:00am-4:30pm. Please sign below to indicate that you have received this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. __________________________________________ Signature of Patient or Authorized Representative _____________ Date Form No. CMS-10095 Exp. Date 03/31/2007 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0910. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form Instructions Notice of Medicare Non-Coverage (NOMNC) “The Advance Notice” CMS-10095-A A MedicareAdvantage (MA) provider must deliver an advance, completed copy of this notice to enrollees receiving skilled nursing, home health or comprehensive outpatient rehabilitation facility services not later than 2 days before the termination of services. This notice fulfills the requirement at 42 CFR § 422.624(b)(2). This is a standard notice. MA providers may not deviate from the content of the form except where indicated. (You may modify the form for mass printing to indicate the kind of service being terminated if only one type of service is provided, i.e., skilled nursing, home health, or comprehensive outpatient rehabilitation.) In situations where the termination decision is not delegated to the provider, the MA plan must provide the termination of services date to the provider not later than 2 days before the termination of services for timely delivery to occur. The NOMNC should not be used when MA plans determine that an enrollee’s services should end based on the exhaustion of Medicare benefits (such as the 100-day SNF limit). Instead, MA plans must issue the Notice of Denial of Medical Coverage. MA plans and providers will note that the notice must be validly delivered. Valid delivery means that the enrollee must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The enrollee must be able to understand that he or she may appeal the termination decision. If the enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative of the enrollee. Valid delivery does not preclude the use of assistive devices, witnesses, or interpreters for notice delivery. Thus, if an enrollee is able to comprehend the notice, but either is physically unable to sign it, or needs the assistance of an interpreter to translate it or an assistive device to read or sign it, valid delivery may be achieved by documenting the use of such assistance. Furthermore, if the enrollee refuses to sign the notice, the notice is still valid as long as the provider documents that the notice was given, but the enrollee refused to sign. Notice Delivery to Authorized Representatives CMS requires that notification of changes in coverage for an enrollee who is not competent be made to an authorized representative acting on behalf of the enrollee. Notification to the authorized representative may be problematic because he or she may not be available in person to acknowledge receipt of the required notification. MA plans and providers are required to develop procedures to use when the enrollee is incompetent or incapable of receiving the notice, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact. • If the provider is unable to personally deliver a notice of noncoverage to a person legally acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee’s services are no longer covered. • The enrollee’s appeal rights must be explained to the representative, and the name and telephone number of the appropriate quality improvement organization (QIO) should be provided. • The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. • Place a dated copy of the notice in the enrollee’s medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. • When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. • The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date of receipt. • Place a copy of the notice in the enrollee’s medical file and document the attempted telephone contact to include: the name of person initiating the contact, the name of the representative you attempted to contact, the date and time of the attempted contact and the telephone number called. • When notices are returned by the post office, with no indication of a refusal date, then the enrollee’s liability starts on the second working day after the provider’s mailing date. These procedures also may be used where an enrollee has authorized an individual to act on his or her behalf, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact. INSTRUCTIONS FOR CMS-10095-A PAGE 1: Heading: MA plans and/or providers must be identified in this space. Logos may be used if they include the name of the organization, address and telephone number of the organization responsible for the termination decision above the title of the notice. Patient Name: Insert the patient’s full name. Patient ID Number: Insert a unique patient identifier such as the HIC number or Medical Record number, if applicable. THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type} SERVICES WILL END: {insert effective date}: Fill in the type of services ending, {home health, skilled nursing, or comprehensive outpatient rehabilitation services} and the actual date the covered service will end. The date should be in no less than 12point type. Note that if the effective date for the service termination changes after delivery of the notice, the provider may contact the patient or authorized representative by phone to inform him or her of the new service termination date. Confirm the telephone contact by written notice mailed on that same date. YOUR RIGHT TO APPEAL THIS DECISION Bullet # 1 Bullet # 2 N/A N/A 2 Bullet # 3 Bullet # 4 Bullet # 5 N/A N/A N/A HOW TO ASK FOR AN IMMEDIATE APPEAL Bullet # 1 Bullet # 2 Bullet # 3 Bullet # 4 N/A N/A N/A Insert the name and telephone numbers (including TTY/TDD) of the applicable QIO in no less than12-point type. INSTRUCTIONS FOR CMS-10095-A PAGE 2 - Signature page: OTHER APPEAL RIGHTS Bullet # 1 Bullet #2 N/A N/A ADDITIONAL INFORMATION (OPTIONAL) This space is available, at the option of the plan or relevant provider, to furnish additional relevant information to the enrollee, such as further details about the reason for the service termination, or the timing of any additional liability risk. The use of this space does not replace the requirement to provide the Detailed Notice of Non-Coverage (DENC) to either the enrollee or the QIO when an appeal is filed. Signature line: The enrollee or the authorized representative must sign this line. Date: The enrollee or the authorized representative must fill in the date that he or she signs the document. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0910. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 3