Optional Form To Document Alternate Delivery printable pdf download

Optional Form to Document Alternate Delivery

Please fax completed (signed) Notice of Medicare Non-Coverage (NOMNC) to: _________________

CONFIRMATION OF NOTICE BY TELEPHONE

(Notification by telephone is done only in situations where the notice must be delivered to an enrollee in an institutional setting, who is unable

to make decisions for him/herself. See Medicare Managed Care Manual, Chapter 13, Section 60.1.3 for reference.)

Name of person contacted:

Date of contact:

_____________________________

Time:

Telephone Number called: ____

_____________________________________________________

_____________

Signature of Health Plan/SNF/HHA/CORF/Medical Group Representative

Date

CONFIRMATION OF FOLLOW-UP NOTICE BY MAIL

(Notification by mail must also be done if telephone notification was made. This is done only in situations where the notice must be delivered

to an enrollee in an institutional setting, who is unable to make decisions for him/herself. See Medicare Managed Care Manual, Chapter 13,

Section 60.1.3 for reference.)

Mailing address:

__________________________________________________________________________________________

_____________________________________________________________________________________________________________

Date sent:

Via:

US Mail

Certified Mail

FedEx

Priority Mail

Tracking # (if applicable):

____________________________________________

CONFIRMATION OF REFUSAL TO SIGN

I confirm that the Notice of Medicare Non-Coverage was hand-delivered to the member or the member's authorized representative; however,

the member or the member’s authorized representative refused to sign the acknowledgment of receipt.

Name of person receiving notice:

Date of delivery:

Time:

____________________________________________________

________________

Signature of Person Delivering Notice

Date

_____________________________________________________

________________

Signature of Witness to Delivery of Notice

Date

Guidance Checklist When Issuing NOMNC to Other Than Member

Responsible Party

Initial

Date

Time

(See Medicare Managed Care Manual, Chapter 13, Section 60.1.3)

Completed

SNF

MG/IPA

Call patient’s representative the day notice is issued. (Date of conversation is the date of the receipt of the

NONMC). ID self and give organization, contact name and number, purpose of call (right to file an appeal)

and describe the appeal right being discussed (e.g. QIO vs expedited).

Inform representative that skilled services will no longer be covered beginning on: (date) _______ and

financial responsibility starts on (date) _________________________.

Advise representative of appeal rights. (You must read directly from the letter.)

Advise representative that an appeal must be phoned to Livanta by 12:00 pm the following day of receipt of

the NOMNC or phone call.

Provide the representative with the QIO name (Livanta) and phone number listed in the appeal section of the

letter. Provide address, fax or other method of communication needed by representative for QIO to receive

appeal in a timely fashion.

Inform representative how to get a detailed notice describing why the enrollee’s services are not being

covered.

Provide at least one phone number of an advocacy organization or 1-800-MEDICARE.

Confirm the telephone contact by written notice mailed same day.

If direct phone contact cannot be made, including leaving voice mail, mail the notice to the representative,

certified mail, return receipt requested. (If the Medical Group is sending the certified mail, the Facility must

notify the Medical Group immediately that certified mail is required.)

(If the Facility sent the certified mail, and Livanta is processing an appeal, the certified returned receipt must

be submitted to Livanta. If not submitted, the appeal may be decided in favor of the member solely due to

lack of the receipt which is the evidence of timely notification.)

Document that representative verbalizes understanding of the information provided.

Optional Form To Document Alternate Delivery

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