notice of medicare non-coverage (nomnc)

Pennsylvania Client Admission Packet ACHC Medicare

Agency Name: Racheal Home health Care Inc.

Agency Phone Number: 717-747-1159

Agency Address: 320 Loucks road Suite 102, York, PA 17404

Notice of Medicare Non-Coverage

Patient Name:

Patient Number:

The Effective date coverage of your current

Services will end:

Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current

[insert type] 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. 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,
atter the effective date indicated above;

Neither Medicare, nor your plan, will pay for these services, after that day

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 you 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 possiblem but no later than noon, of the day before, the effective date indicated above.
The QIO will notify you of its decisionm as soon as possiblem 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: Livanta 1-888-396-4646 to appeal, or if you have questions.

If you miss the DEaline to Request an Immediate Appeal, You may have other appeal rights:

If you have Original Medicare: Calll the QIO listied above.
If you belong to a Medicare health plan: Call your plan at the number given below.

Plan contact information

Additional Information (Optional)

Please sign below to indicate you received and understood this notice.

I have been notified that coverage of my services will end on the effective date, indicated on this notice, and that I may appeal this decision, by contacting my QIO.

notice of medicare non-coverage (nomnc)

Pennsylvania Client Admission Packet ACHC Medicare