Response to Comments

We recommend including more empathetic language that speaks to the member's circumstances in this fast track appeals notice. (Ex. We know that getting quality care is important to you. If you disagree with this decision, you have the option to ask for your case to be re-reviewed.)

Thank you for your feedback on the Notice of Medicare Non-Coverage (NOMNC). The NOMNC is written in beneficiary-friendly, plain language that has been consumer tested.

The NOMNC required language specifically addresses a beneficiary’s right to appeal…..

• 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.

We recommend giving plans the option to include an accompanying cover letter with the notice to further explain the decision to terminate services.

Per current instructions (Section 260.4.5 of Chapter 30 of the Medicare Claims Processing Manual https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf and Section 90.6 of Chapter 13 of the Medicare Managed Care Manual https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c13.pdf), any beneficiary that wishes to dispute the termination of services must receive the CMS 10124, the ‘Detailed Notice of Non-Coverage’ (DENC).

The DENC accompanies the NOMNC in this notice renewal package. The DENC must contain the facts specific to the beneficiary’s discharge and provider’s determination that coverage should end, a specific and detailed explanation of why services are either no longer reasonable and necessary or no longer covered, and the Medicare and or Plan/coverage rules applicable to the review.

Finally, per current instructions, as cited above, any provider may choose to deliver the DENC with the NOMNC.

We are concerned about the effectiveness of this notice for beneficiaries in certain care facility settings. For example, beneficiaries residing in hospice care or skilled nursing facilities may not receive this notice because they are likely not receiving and/or reading their own mail. CMS should consider methods to ensure beneficiaries receive this notice, such as through the designation of a caretaker.

Section 260.3.8 of Chapter 30 of the Medicare Claims Processing Manual https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf), and Section 90.2 of Chapter 13 of the Medicare Managed Care Manual, contain current instructions for delivery of the NOMNC to representatives.

Specifically, the instructions require that the NOMNC be delivered to a representative appointed via the ‘Appointment of Representative’ form, the CMS-1696. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.html and https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c13.pdf See Chapter 29 of the Medicare Claims Processing Manual, Section 270.1 and Chapter 13 of the Medicare Managed Care Manual, Section 10.4, for more information on appointed representatives.

If a beneficiary has been deemed legally incompetent, delivery of the NOMNC may be made to an authorized representative of the beneficiary.

The current instructions, as cited above, also describe the procedures for delivery of the NOMNC to a representative not living with, or presently visiting, the beneficiary.