If you are losing services from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF) or hospice because they believe Medicare will not pay for your care any longer, you can appeal.
Your doctor or other health care provider should give you a notice called a Notice of Medicare Non-Coverage (NOMNC). The NOMNC tells you when care is scheduled to end and how you can contact a Quality Improvement Organization (QIO) to appeal. You should appeal to the QIO if you think you need more care. The QIO is an independent group of medical professionals that contracts with Medicare to ensure people with Medicare get good quality care.
You should typically receive the NOMNC no later than two days before care is set to end. If you begin your appeal with the QIO in time, your care must continue during your appeal and you cannot be charged for care until the QIO makes its decision.
Note: You will only receive the NOMNC if your care is ending because your doctor or other health care provider determined you are no longer eligible for care under Medicare coverage rules. You will not get the notice if you are losing coverage for another reason. For example, if the skilled nursing facility does not have the staffing or capacity to care for you, or you have exhausted the Medicare covered days you can remain in the facility, you will not get the NOMNC. In these cases, you must find another facility or agency in your plan’s network.
How to Appeal
- Once you receive an NOMNC, you should notify the QIO that you want to appeal. You should do this by noon the calendar day before care is set to end.
- If you are receiving home health (HHA) care or comprehensive outpatient rehabilitation facility (CORF) care, you will need to include in your appeal a written statement from your doctor that states that ending services may harm your health.
- On the day the QIO receives your request, it must immediately notify your doctor or other health care provider that you have requested an appeal. Your provider must give you a Detailed Explanation of Non-Coverage (DENC) by the close of business that day. The DENC will explain why the services will no longer be provided and any applicable Medicare coverage rules.
- Your provider must submit evidence to the QIO regarding your appeal and you have the right to ask for a copy of that evidence.
- You can submit your own evidence in the appeal, but it is not required.
How Long Does the QIO Have to Make a Decision?
- The QIO must make its decision and notify you and your doctor or other health care provider no later than two days after the NOMNC said services would end.
- If you requested QIO review after the appeal deadline and are still receiving services, the QIO will make its decision as soon as possible. However, the provider can charge you before the QIO makes its decision. The provider must refund you back to the discharge date if the QIO finds in your favor
- The QIO decision can be by telephone, as long as it is followed up in writing.
What Happens Once the QIO Makes a Decision?
- If you win your appeal with the QIO (they decide in your favor), your care should continue. Before the facility/provider decides to end services again, you should get another notice and will have the right to another QIO review.
- Although you can’t be billed while the QIO is reviewing your appeal, you may have to pay for up to two days of care if your lose your appeal. The QIO decision will typically be made about two days after your care was originally scheduled to end. You will have to pay for the cost of care received after the date and you’re your care was scheduled to end which is indicated on the NOMNC.
- If you feel that you still need care, you can continue to appeal. During your appeal, the provider cannot end your services and cannot charge you until the next review body (the Qualified Independent Contractor) makes its decision.
If you miss the deadline to appeal, you can still request a QIO review within 60 days of the date coverage was set to end (regardless of whether you are still receiving services).