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Notice of Medicare Non-Coverage (NOMNC) checklist for
Skilled Nursing Facilities (SNF)
Use this checklist to ensure you thoroughly and accurately complete the NOMNC form. A NOMNC must
be issued a minimum of 2 days prior to the last day the patient is anticipated to be at SNF level of care.
NOMNCs can be issued earlier to accommodate a weekend or to provide a longer transition period. With
respect to weekends, although Quality Improvement Organizations (QIO) are open, Regence is closed.
Providers should try to deliver the Regence NOMNC form early enough in the week to minimize the
possibility of extended liability for weekend services.
Completing the NOMNC form
 The last day of covered SNF level care is identified and discussed with the patient and family or
authorized representative.
 SNF selects the Regence SNF NOMNC form. Be sure to select the correct version of the form.
Versions vary by service area. Verify that the form includes the following elements:
 The type of service to be terminated (Skilled Nursing Services, Home Health Services or
Comprehensive Outpatient Rehabilitation Services) is listed in the two fields referring to
termination of services, in the first and second sections of the form. (These fields are
identified by the instruction “Insert Type.”)
 Accurate Regence contact information
 Correct QIO information for the service area
 The delivering provider’s name, address and telephone number is entered above the title
of the form.
 The patient name and the Regence member number are entered in the top section of the
form. If the Regence member number is not available, the facility medical record number
can be used. Do not use the patient’s Medicare number.
 The last covered day is entered on the form. The signature date must be two days prior to
last covered day
 The patient or authorized representative signs the NOMNC form on page 2. If the patient
is unable to sign, and the SNF is working with an authorized representative who is unable
to be present at the facility that day, the SNF may issue the NOMNC by telephone. For a
telephonic notice to be valid, the documentation on the NOMNC must include all of
the following:





The name of the staff person initiating the contact
The name of the representative contacted by phone
The date and time of the telephone contact
The telephone number called
A notation that full appeal rights were given to the representative
The date of the properly documented telephone conversation is the date of the receipt of
the notice. The facility must confirm the telephone contact by sending written notice to the
authorized representative on that same date.
 Copies of the completed NOMNC are:
1. Given to the patient or the authorized representative who signed the NOMNC
2. Placed in the patient’s medical record at the SNF
3. Faxed to Regence at 1 (855) 240-6498 as soon as possible after the form is signed
 Contact your provider relations representative or Regence MedAdvantage Provider Customer
Service if you have additional questions.
Regence NOMNC instructions
Revised October 2012
Discharge and appeals



The patient may choose to discharge sooner than the designated day. In this case, the
NOMNC must still be signed, and a note should be added detailing the circumstances of the
early discharge.
If the patient chooses to appeal, he or she must contact the QIO to request a review no later than
noon on the day before services are to end. The QIO appeal decision will generally be completed
within 48 hours of the patient's request for a review.
If the patient appeals, the SNF should be prepared to provide documentation to Regence quickly
to assist the review process.
Skilled Nursing Facility sample scenario:
On May 25th, Jane Doe is admitted to a SNF after surgery. On June 2nd, Regence MedAdvantage
contacts the SNF to deliver a Regence NOMNC form to Ms. Doe indicating her last approved day will be
June 4th, with discharge to a lower level of care on June 5th.
Date
Member agrees with
discharge
Jane Doe is admitted to SNF
NOMNC Distribution Date
Jane Doe receives advance
notice that June 4th will be
the last SNF day paid by
Regence MedAdvantage
Member disagrees with
discharge
Jane Doe is admitted to SNF
NOMNC Distribution Date
Jane Doe receives advance
notice that June 4th will be
the last SNF day paid by
Regence MedAdvantage
June 3rd
Jane continues to receive
SNF-level services
Jane files an appeal with the
QIO by noon and continues
to receive SNF-level
services
June 4th
Last Authorized Day
Jane continues to receive
SNF-level services
June 5th
Jane discharges to lower
level of care as planned
Last Authorized Day
Jane continues to receive
SNF-level services and
should receive QIO decision
by end of day
If QIO upholds NOMNC,
member is liable for cost of
care starting today. If QIO
overturns NOMNC or
determines a new discharge
date, Regence is liable for
cost of care today.
May 25th
June 2nd
Steps



SNF delivers Regence
NOMNC form
Member or authorized
representative signs
Copies to member,
medical record and
Regence (by fax)
QIO notifies Regence to
provide medical information
and detailed notice to the
QIO by end of day. SNF may
be asked to provide copy of
the signed NOMNC and
medical records.
QIO can overturn, uphold or
determine a new discharge
date and will notify the
member of its decision by
end of day.
QIO informs Regence of its
decision. Regence contacts
SNF to extend the
authorization if NOMNC is
overturned or new discharge
date was determined.
Regence NOMNC instructions
Revised October 2012
<
Provider Name>
Insert provider name and address
<Provider Address>
<Pro
Insert
telephone
number
vider Phone Number>
Notice of Medicare Non-Coverage
patientName>
name
Patient Name: Insert
<Member
Patient Number: Insert
<Subscriber
RegenceID>
member number
Insert type
of services ending
The Effective Date Coverage of Your Current
Comprehensive
Outpatient Physical
Services Will End: Last covered day
_____________________________

Your Medicare provider and/or health plan have determined that Medicare
Insert type
of services ending
probably will not pay for your current Current
Comprehensive
Outpatient Physical
services after the effective date indicated above.

You may have the pay for any services you receive after the above date.
Your Right to Appeal This Decision

You have the right to an immediate, independent medical review (appeal) of the
decision to end Medicare coverage of these services. Your services will continue
during the appeal.

If you choose to appeal, the independent reviewer will ask for your opinion. The
reviewer also will 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 services should no
longer be covered after the effective date indicated above:
o Neither Medicare nor your 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.

The QIO will notify you of its decision as soon as possible, generally no later than
two days after the effective date of this notice if you are on Original Medicare. If
you are in a Medicare health plan, the QIO generally will notify you of its decision
by the effective date of this notice.

Call your QIO at: Qualis Health, 1 (877) 290-4346 (TTY: 711) to appeal, or if you have
questions.
Form CMS 10123-NOMNC (Approved 12/31/2011)
OMB approval 0938-0953
See page 2 if this notice for more information
If You Miss The Deadline to Request An Immediate Appeal, You Might
Have Other Appeal Rights:

If you have Original Medicare: Call the QIO listed on Page 1.

If you belong to a Medicare health plan: Call your plan at the number given
below.
Plan contact information: Regence MedAdvantage
PO Box 12625
Salem, OR 97309
1 (866) 749-0355 (TTY: 711)
Additional Information (Optional):
Please sign below to indicate you received and understood 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 Representative
Form CMS 10123-NOMNC (Approved 12/31/2011)
___________________
Date
OMB approval 0938-0953