To ensure that all service determinations are appropriate and consistent with Centers for Medicare & Medicaid Services (CMS) requirements, delegated providers 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.

Medicare Advantage (MA) providers may download the CMS-approved templates from the ICE website at www.iceforhealth.org Providers may also download the forms from the CMS website at www.cms.gov.