The NOMNC Appeal Process

Medicare regulations require the provider to deliver the standard Notice of Medicare Non Coverage (NOMNC) to all members when covered services are ending, whether or not the member agrees with the plan to end services. Here’s how:  

• The provider delivers the NOMNC to members at least two calendar days before coverage ends. If the member is receiving home health agency services and the span of time between services exceeds two days, the provider may deliver the NOMNC at the next-to-last time that services are furnished. The form must be delivered whether or not the member agrees with the plan to end services.  

Special considerations related to delivery of the NOMNC: 

• Blue Cross and Blue Shield of Nebraska (BCBSNE) encourages providers to deliver the notice no sooner than four calendar days before discharge. If the notice is delivered too early, it could result in a premature request for a review by the QIO. 
• If services are expected to be less than two days in duration, the provider may deliver the NOMNC at the start of service. A member who receives the NOMNC and agrees with the termination of services before the end of the two days may waive the right to request the continuation of services.  
• If the member is not mentally competent to receive the notice, the provider must deliver it to the member’s authorized representative.  
• The provider requests that the member sign and date the NOMNC, acknowledging receipt of their appeal rights. If the member refuses to sign the form, the facility must record the date and time it was delivered to the member.  

The provider must fax the signed NOMNC for Skilled Nursing Facilities back to BCBSNE at 866-422-5120, Attention: Medical Records.  

The provider is expected to retain a signed copy of the NOMNC form with the member’s medical record. The member is responsible for contacting the QIO by noon of the day before services end if they wishes to initiate an expedited review by following the detailed instructions on the form.  

When the member initiates an expedited review, the Detailed Explanation of Non-Coverage (DENC) is delivered to the member by the close of business on the same day that the QIO is notified of the member’s request for appeal. The DENC provides specific and detailed information as to why the member’s SNF, HHA or CORF services are ending.  

Note: The DENC must be completed and submitted by the entity that determines that covered services are ending, whether it is BCBSNE or the SNF, HHA or CORF provider.  

BCBSNE may request medical records or other pertinent clinical information from the provider to assist with the completion of this step within the short time frames mandated by CMS regulations.  

A copy of the DENC is also sent to the QIO. 

The expedited review process conducted by the QIO is usually completed within 48 hours. The provider, the member and BCBSNE are notified of the decision by the QIO.

If the member is late or misses the noon deadline to file for an immediate review by the QIO, they may still request an expedited appeal from BCBSNE.