This is a reminder that under the Medicare Advantage (MA) program, home health agencies (HHAs), skilled nursing facilities (SNFs), and comprehensive outpatient rehabilitation facilities (CORFs) are required to provide a specific CMS approved notice to Medicare Advantage members to alert them that Medicare covered items and/or services are ending and to give them the opportunity to request an expedited determination from a quality improvement organization (QIO).

A Medicare Advantage provider must deliver an advance, completed copy of the Form No. CMS-10095A to MA members receiving HHA, SNF or CORF services no later than two (2) days before the termination of services. The delivery of this notice fulfills the requirement at 42 CFR, §422.624(b)(2).

This is a standard notice.  Providers may not deviate from the content of the form except where indicated. (The form may be modified for mass printing to indicate the kind of service being terminated if only one type of services provided, i.e., skilled nursing, home health, or comprehensive outpatient rehabilitation).  Providers can download the Notice of Medicare Noncoverage (Form No. CMS-10095A) from the Centers for Medicare and Medicaid Services (CMS), or providers may use the Form No. CMS-10095A.

The notice must be validly delivered. Valid delivery means that the member must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The member must be able to understand that he or she may appeal the termination decision. If the member is not able to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative of the member. Valid delivery does not preclude the use of assistive devices, witnesses, or interpreters for notice delivery. Thus, if a member is able to comprehend the notice, but either is physically unable to sign it, or needs the assistance of an interpreter to translate it or an assistive device to read or sign it, valid delivery may be achieved by documenting the use of such assistance. If the member refuses to sign the notice, the notice is still valid as long as the provider documents that the notice was given but the member refused to sign.  More information regarding Notice of Medicare Noncoverage can be found at: www.cms.hhs.gov/MMCAG.