CMS Pub. 100-04, ch. 30, § 260.3.8

The NOMNC may be delivered to a beneficiary’s appointed or authorized representative.

Appointed representatives are individuals designated by beneficiaries to act on their

behalf during the appeal process. A beneficiary may designate an appointed

representative via the “Appointment of Representative” form, the CMS-1696.

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf See

Chapter 29 of the Medicare Claims Processing Manual, section 270.1, for more

information on appointed representatives.

CMS usually requires that notification to a beneficiary who has been deemed legally

incompetent be made to an authorized representative of the beneficiary. Generally, an

authorized representative is an individual who, under State or other applicable law, may

make health care decisions on a beneficiary’s behalf (e.g., the beneficiary’s legal

guardian, or someone appointed in accordance with a properly executed durable medical

power of attorney).

However, if a beneficiary is temporarily incapacitated a person (typically, a family

member or close friend) whom the provider has determined could reasonable represent

the beneficiary, but who has not been named in any legally binding document, may be a

representative for the purpose of receiving the notices described in this section. Such a

representative should have the beneficiary’s best interests at heart and must act in a

manner that is protective of the beneficiary and the beneficiary’s rights. Therefore, a

representative should have no relevant conflict of interest with the beneficiary.

In these instances of delivering a notice to an unnamed representative, the provider

should annotate the NOMNC with the name of the staff person initiating the contact, the

name of the person contacted, and the date, time, and method (in person or telephone) of

the contact. A copy of the NOMNC with this information should be retained in the

beneficiary’s record.

Note - Exceptions to in person notice delivery. If the NOMNC must be delivered to a

representative not living with the beneficiary, the provider is not required to make off-site

in- person notice delivery to the representative. The provider must complete the

NOMNC as required and telephone the representative at least two days prior to the end of

covered services. The provider should inform the representative of the beneficiary’s right

to appeal a coverage termination decision.

The information provided should include the following:

• The beneficiary’s last day of covered services, and the date when the

beneficiary’s liability is expected to begin.

• The beneficiary’s right to appeal a coverage termination decision.

• A description of how to request an appeal by a QIO.

• The deadline to request a review as well as what to do if the deadline is

missed.

• The telephone number of the QIO to request the appeal.

The date the provider communicates this information to the representative, whether by

telephone or in writing, is considered the receipt date of the NOMNC.

The NOMNC must be annotated with the following information on the day that the

provider makes telephone contact:

Reflect that all of the information indicated above was communicated to the

representative;

Note the name of the staff person initiating the contact, the name of the representative

contacted by phone, the date and time of the telephone contact, and the telephone number

called.

A copy of the annotated NOMNC should be mailed to the representative the day

telephone contact is made and a dated copy should be placed in the beneficiary’s medical

file.

If the provider chooses to communicate the information in writing, a hard copy of the

NOMNC must be sent to the representative by certified mail, return receipt requested, or

any other delivery method that can provide signed verification of delivery (e.g. FedEx,

UPS) The burden is on the provider to demonstrate that timely contact was attempted

with the representative and that the notice was delivered.

The date that someone at the representative’s address signs (or refuses to sign) the receipt

is considered the date received. Place a copy of the annotated NOMNC in the

beneficiary’s medical file.

If both the provider and the representative agree, providers may send the notice by fax or

e-mail, however, providers fax and e-mail systems must meet the The Health Insurance

Portability and Accountability Act of 1996 (HIPAA) privacy and security

requirements.