See next page of this notice for more information.

Transcription

1 1 Date:. Patient Name: Address: 68 Long Court, Suite 2C, Thousand Oaks, CA T F Notice of Medicare Non-Coverage Service Start/Admission Date: Patient ID Number: Provider/Facility: Los Robles Homecare Services Attending Physician: The Effective Date Coverage of Your Current Home Health Services Will End: Date the NOMNC was signed by patient. Patient s Name Patient s address, found in patient chart. See page 4; step 4 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 SOC Date Kaiser# NOT MR#. See page 4; step 5 Primary Physician See page 4; step 6 ss D/C Date 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 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: Livanta at (TTY: ) to appeal, or if you have questions. See next page of this notice for more information. Form CMS NOMNC (Approved 12/31/2011) OMB Approval Y0043_N File & Use (08/01/2014)

2 2 If You Miss The Deadline to Request an Immediate Appeal, You May Have Other Appeal Rights: If you have Original Medicare: Call the QIO listed on page 1. If you belong to a Medicare health plan: Call your plan at the number given below. Plan Contact Information: Kaiser Foundation Health Plan, Inc. Attention: Expedited Appeals Toll Free: (TTY number: ) Toll Free FAX: 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. Patient s Signature Date NOMNC was signed. Document must be signed at least two days prior to D/C Signature of Patient or Representative Date Patient ID Number: KAISER#, NOT MR#; see page 4; step 5

3 Instructions on how to find the patient s Address (4), Kaiser ID # (5) and Attending Physician (6) Go to the Patient s Chart 2. Select View to access the drop down box. 3. Select Patient Profile

4 4 Patient Chart DOE, JANE ( ) Los Robles Homecare Services (805) Long Court Suite 2C Thousand Oaks CA, Patient Information HIC# Medicaid # SSN Date of Birth (Age) Gender M /02/1930 (84) Female Address Phone 4. The patient s Triage Code Address is located in Referral the Patient Date 212 Willow Lane (805) Information section. Use this information 02/03/2013 to fill out Westlake CA the Address section of the NOMNC Address Insurance Primary Insurance Secondary Insurance Tertiary Insurance KAISER SO CAL MEDICARE HMO Policy Number: Phone Number: (800) Allergies Metoprolol - Rash Current Episode: 06/02/ /31/2014 Primary Diagnosis: Secondary Diagnosis: Primary Clinician Primary Aide Case Manager Rebecca Buck Rebecca Buck Rebecca Buck Frequencies: Start of Care: 04/01/2014 Emergency Contact: Address Phone Relationship Not Entered Primary Physician: Gregory Tchejeyan MD Address Phone Facsimile State ID 2100 Lynn Rd, Suite #115 THOUSAND OAKS CA NPI Pharmacy: Target Phone: Comments (Xxx) Xxx-Xxxx (805) (805) A55364 Contact 5. The KAISER # is the group of numbers after Fill in the Patient ID Number on the Kaiser NOMNC with these numbers. 6. The Primary Physician of the Patient has its own section in the patient chart. Please use this information to fill out the Attending Physician section of the NOMNC

5 5 68 Long Court, Suite 2C, Thousand Oaks, CA T F Notice of Medicare Non-Coverage (EXAMPLE OF COMPLETED NOMNC) Date: 07/23/2014 Service Start/Admission Date: 05/22/2014 Patient Name: Jane Doe Patient ID Number: Address: 212 Willow Lane Provider/Facility: Los Robles Homecare Services Westlake, CA Attending Physician: Gregory Tchejeyan MD The Effective Date Coverage of Your Current Home Health Services Will End: 07/31/2014 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. 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: Livanta at (TTY: ) to appeal, or if you have questions. See next page of this notice for more information.

6 6 If You Miss The Deadline to Request an Immediate Appeal, You May Have Other Appeal Rights: If you have Original Medicare: Call the QIO listed on page 1. If you belong to a Medicare health plan: Call your plan at the number given below. Plan Contact Information: Kaiser Foundation Health Plan, Inc. Attention: Expedited Appeals Toll Free: (TTY number: ) Toll Free FAX: 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. Jane Doe 7/23/ /23/2014 Signature of Patient or Representative Date Patient ID Number: