NOMNC_CE_AllCare

NOTICE OF MEDICARE NON-COVERAGE

(NOMNC)
This Page To Be Completed By Home Health/Hospice Agency Staff
Yes
Yes
Staff Full Name*
Staff Email Address*
STAFF SIGNATURE*

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NOTE: FOR BEST SIGNATURE RESULTS, DO NOT ROTATE PHONE

NOTICE OF MEDICARE NON-COVERAGE

(NOMNC)
Home HealthHospice
Patient Full Name (Last Name, First Name)*
Patient Medical Record Number - (MRxxxxx) or (x01xxxx, x02xxxx)*
Please gather Medical Record Number from Patient Chart. Example MR12345
The Effective Date Coverage of Your Current Services Will End:
Date Services Will End*

MonthDayYear
Signature Date*

MonthDayYear
MINIMUM 48 HOURS PRIOR TO DATE SERVICES WILL END, OR UP TO 2 VISITS PRIOR
- - Your provider and/or health plan determined that Medicare probably won’t pay for your services after the above date. You may have to pay for any services you get after this date. Your right to appeal this decision
  - You have the right to appeal the decision to end Medicare coverage of yourservices. This means you’ll get an independent medical review right away. Your services will continue during the appeal.
  - If you choose to appeal, the independent reviewer will ask for your opinion. Youdon’t have to prepare anything in writing, but you have the right to do so. Thereviewer also will look at your medical records and/or other relevant information.
  - Once you ask for an appeal, you’ll get a notice with a detailed explanation about why your service coverage should end.
  - If the independent reviewer agrees Medicare coverage for your services shouldend, neither Medicare nor your plan will pay for these services after the above date.
    
    •If you stop services by the above date, you’ll avoid financial liability.
    
    How to ask for an immediate appeal
  - Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date.
  - Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare.
  - If you miss the deadline to ask for an immediate appeal, you may still have appeal rights.
  - Call your QIO at Acentra Health: 888-317-8091 to appeal, or if you have questions.
    
    What happens next
  - The QIO will let you know its decision as soon as possible, generally no later than two days after the effective date above. If you’re in a Medicare health plan, the QIO generally will let you know its decision by the effective date above.
  - Call your QIO at Acentra Health: 888-317-8091 to learn more.
- Sign below to show you received and understand this notice.
  
  I’ve been notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO.

SIGNATURE FIELD TO BE COMPLETED BY PATIENT ONLY!
I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting "I agree" using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Signature of Patient or Representative*

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FOR BEST SIGNATURE RESULTS, DO NOT ROTATE PHONE
Form CMS 10123-NOMNC (Exp 11/30/2027)
(OPTIONAL) PATIENT EMAIL ADDRESS
If patient would like a copy of the signed NOMNC form emailed to them
Should be Empty:

NOTICE OF MEDICARE NON-COVERAGE

This Page To Be Completed By Home Health/Hospice Agency Staff

NOTICE OF MEDICARE NON-COVERAGE

SIGNATURE FIELD TO BE COMPLETED BY PATIENT ONLY!