Checklist for Issuing a Notice of Medicare Non-Coverage by eddie11


									Checklist for Issuing a Notice of Medicare Non-Coverage
                  (Applies to Medicare Advantage Enrollees)

  □ Are you using the correct form? It should be “CMS-10095; Exp Date 3/31/2007.”
  □ Is the heading correct? Both the MA plan and SNF may be identified; however, the
     heading must include the name, address, and phone number of the organization responsible
     for the termination decision.

  □ Is the effective date that coverage will end clearly stated under the heading?
     The notice should read, “The effective date coverage of your current skilled nursing
     services will end: [effective date, e.g., March 30, 2005].”
            Effective date must be at least two days after the issue date
            Services must continue through the effective date

  □ Is the font at least 12 points? The notice will be two pages long if it’s in the correct font.
  □ Does the first paragraph include the type of current services?
  □ Are appeal rights stated? There should be a section titled “YOUR RIGHT TO APPEAL

  □ Is the procedure for appeal included? There should be a section titled “HOW TO ASK

  □ Have you included Acumentra Health’s name and toll-free number?
            The number should be 1-800-785-0411. This is the only number that can be used for
             weekend contact. Notices without this number will be considered invalid and a new
             notice will need to be issued.

  □ Have you included “Other Appeal Rights”?
  □ Has the document been signed appropriately? The date of the signature must be at least
     two days before the effective date coverage will end.
            Is the beneficiary competent to sign the notice? If not, you must follow your policy
             to obtain the signature from an authorized representative. You may not issue a notice
             to an incompetent beneficiary, even if the incompetence is of a temporary nature.

  □ What if the person with power of attorney for the beneficiary is not available to sign?
     Call the beneficiary representative and explain the appeal procedure, which includes giving
     them OMPRO’s toll-free phone number. Document on the notice the date and time you
     contacted the representative, and that you explained the appeal rights and gave OMPRO’s
     phone number. If these items are not documented, the notice will be considered invalid.
                                         This material was prepared by Acumentra Health, Oregon’s Medicare Quality Improvement
                                         Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an
                                        agency of the U.S. Department of Health and Human Services. The contents presented do not
                                                              necessarily reflect CMS policy.7SOW-OR-REV-05-01 rev. 11/9/05

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