Notice of Medicare Non-Coverage and Detailed Explanation of Non-Coverage
- Participating Physician Groups (PPG)
The Notice of Medicare Non-Coverage (NOMNC) is a written notice designed to inform Medicare members that their covered skilled nursing facility (SNF), home health agency (HHA) or comprehensive outpatient rehabilitation facility (CORF) care is ending. The Detailed Explanation of Non-Coverage (DENC) is a standardized written notice that provides specific and detailed information to Medicare members of why their covered SNF, HHA or CORF services are ending.
To ensure that all service determinations are appropriate and consistent with Centers for Medicare & Medicaid Services (CMS) requirements, delegated participating physician groups (PPGs) and their subcontracting medical providers must work together to issue NOMNC letters to members who are being discharged from a SNF, HHA or CORF when services are ending. It is the SNF, HHA or CORF's responsibility to physically deliver the notice to the member within the required time frames.
The provider that delivers the NOMNC notice must list its contact information in the header section of the NOMNC. For example, if staff at the SNF delivers the notice, the SNF's contact information must be listed. The entire notice must fit on two pages. There are no additional pages to this document.
The provider that delivers the DENC must also list its contact information in the header section of the DENC. The name, address and toll-free number of the provider or plan that actually delivers the notice must appear above the title of the form. The entity's registered logo is not required, but may be used. If providers do not have their own toll-free numbers, they must insert their contact information, along with Health Net's Customer Contact Center that is located on the back of the member's identification (ID) card, above the title of the form.
Quality Improvement Organization Appeals
Members or the member's authorized representative have the right to appeal the decision to terminate services from a SNF, HHA or CORF to the Quality Improvement Organization (QIO) appeals. If an appeal is requested by the member or member's authorized representative, the delegated PPG or Health Net must issue a DENC to the member as well as provide all requested medical records, as required by the QIO, as soon as possible, but no later than 4:30 p.m. on the day the QIO notifies Health Net.
The QIO, which operates 365 days a year, notifies Health Net upon making a determination. A representative from Health Net contacts the hospital or the SNF, HHA or CORF and PPG case manager to inform him or her of the appeal determination, including on weekends and holidays.
In addition, if the QIO reverses any determination decision to terminate SNF, HHA or CORF services, the delegated PPG or their subcontracting medical providers must provide the member with a new NOMNC, consistent with CMS regulation 42 C.F.R. Section 422.626(e).
Dual-Risk PPG Responsibilities
Health Net notifies the delegated PPG of the appeal request. All required CMS notices and records must be provided to the member and the QIO in accordance with the appeal request within the required CMS timelines. If Health Net requests a copy of the signed NOMNC or DENC, it must be sent to Health Net within five business days.
Shared-Risk PPG Responsibilities
When Health Net notifies the delegated PPG of the appeal, the delegated PPG must then prepare and provide to Health Net a completed DENC using the CMS-approved Health Net DENC template within two hours of notification of the appeal request if the appeal is received prior to 1:00 p.m. If the appeal is received after 1:00 p.m., the DENC is due to Health Net by 3:00 p.m. in order for the DENC to be delivered to the member by 4:30 p.m. to meet timeliness standards. Delegated PPGs must also provide a copy of the signed NOMNC to Health Net at the time of delivery of the DENC to Health Net.