Page 41 - Home Health Marketing

Agency Name
Address
Phone Number

Notice of Medicare Non-Coverage

Patient name: _____________________ Patient number: _____________________

The Effective Date Coverage of Your Current Home Health
Services Will End: _____________________
SAMPLE
• Your Medicare provider and/or health plan have determined that Medicare
probably will not pay for your current Home Health services after the effective date
indicated above.

• You may have to pay for any services you receive after the above date.

Your Right to Appeal This Decision
• 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.

• If you choose to appeal, the independent reviewer will ask for your opinion. The
reviewer also will look at your medical records and/or other relevant information.
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You do not have to prepare anything in writing, but you have the right to do so if
you wish.

• If you choose to appeal, you and the independent reviewer will each receive a
copy of the detailed explanation about why your coverage for services should not
continue. You will receive this detailed notice only after you request an appeal.

• If you choose to appeal, and the independent reviewer agrees services should no
longer be covered after the effective date indicated above;
º Neither Medicare nor your plan will pay for these services after that date.

• If you stop services no later than the effective date indicated above, you will avoid
financial liability.

How to Ask For an Immediate Appeal

• You must make your request to your Quality Improvement Organization (also
known as a QIO). A QIO is the independent reviewer authorized by Medicare to
review the decision to end these services.

• Your request for an immediate appeal should be made as soon as possible, but no
later than noon of the day before the effective date indicated above.

• The QIO will notify you of its decision as soon as possible, generally no later than
two days after the effective date of this notice if you are in Original Medicare. If you
are in a Medicare health plan, the QIO generally will notify you of its decision by
the effective date of this notice.

• Call your QIO at: _______________________ to appeal, or if you have questions.

See page 2 of this notice for more information.
Form CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953