The Centers for Medicare and Medicaid Services (CMS) has updated certain Medicare beneficiary non-coverage notice forms that apply to both Medicare Fee-for-Service and Medicare Advantage covered beneficiaries. They will become effective January 1, 2025.
Fee-for-Service Medicare Providers
SNFs are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO.
A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered services.
Medicare Advantage Plans
The NOMNC has been modified to reflect regulations providing enrollees additional fast-track appeal rights when they untimely request an appeal to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or still wish to appeal after they end services on or before the planned termination date. (See: CMS-4205-F, p. 30827.)
Additionally, DENC instructions have been updated to include a new element for health plans to complete for the DENC. Specifically, if the enrollee has previously received a favorable BFCC-QIO appeal decision during the current episode of care, MA plans must detail the specific change(s) in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.
For more information, see the “downloads section of the CMS FFS & MA NOMNC/DENC webpage for the updated forms and instructions. Questions regarding the NOMNC and DENC can be submitted here.