CMS Pub. 100-04, ch. 30, § 260.4.5

The DENC is subject to the Paperwork Reduction Act Process and approval by the Office

of Management and Budget. OMB-approved notices may only be modified as per their

accompanying instructions. Unapproved modifications may invalidate the DENC. The

notice and accompanying instructions may be found online at

http://www.cms.gov/Medicare/Medicare-General-Information/BNI. Medicare providers

are responsible for the delivery of the DENC to beneficiaries who request an expedited

determination by the QIO.

The DENC must contain the following information:

• The facts specific to the beneficiary’s discharge and provider’s determination that

coverage should end.

• A specific and detailed explanation of why services are either no longer

reasonable and necessary or no longer covered.

• A description of, and citations to, the Medicare coverage rule, instruction, or other

policies applicable to the review.

The provider should make insertions on the notice in Spanish, if necessary. If this is

impossible, additional steps should be taken to ensure that the beneficiary comprehends

the content of the notice. Providers may resource CMS multilingual services provided

through the 1-800-MEDICARE help line if needed.

The delivery must occur in person by close of business of the day the QIO notifies the

provider that the beneficiary has requested an expedited determination. A provider may

also choose to deliver the DENC with the NOMNC.

The DENC does not require a signature but should be annotated in the event of a

beneficiary’s refusal to accept the notice upon delivery.

Note: An HHA is not required to make a separate trip to the beneficiary’s residence

solely to deliver a DENC. Upon notification from the QIO of a beneficiary’s request for

an expedited determination, an HHA may telephone the beneficiary to provide the

information contained on the DENC, annotate the DENC with the date and time of

telephone contact and file with the beneficiary’s records. A hard copy of the DENC

should be sent to the beneficiary via tracked mail or other personal courier method by

close of business of the day the QIO notifies the provider that the beneficiary has

requested an expedited determination. The burden is on the provider to demonstrate that

timely contact was attempted with the beneficiary and that the notice was delivered.

DENC delivery to representatives, DENC hours of delivery, and DENC retention

requirements are the same as the NOMNC requirements outlined in §260.3.

Expedited Determination Scenario in a Skilled Nursing Facility - Example

On June 2nd, the SNF delivers a NOMNC to Bob Mills notifying him that his Medicare

covered stay will end on June 4th. Bob decides to request an expedited determination.

June 2nd June 3nd June 4rd June 5th June 6th

NOMNC

Delivered

Bob receives a

NOMNC

indicating that

his coverage is

ending June 4th.

Bob must request

an expedited

determination by

noon today.

NOMNC

Effective Date

This is the last day

of coverage, as

stated on the

NOMNC.

If Bob made his

request on June

2nd:

The QIO makes its

decision and notifies

Bob and the SNF by

COB.

If Bob made his

request on

June 3rd:

The QIO makes its

decision and

notifies Bob and

the SNF by COB.

The QIO must

notify the SNF of

Bob’s request for

an expedited

determination.

The SNF must

deliver the

DENC to Bob by

COB today.

The SNF must

provide relevant

medical records

to the QIO by

COB today.

The beneficiary

has no liability

for this day as

this is the last day

of coverage in the

SNF.

If QIO decision is

unfavorable:

Beginning today

Bob is liable for his

stay if he does not

leave the SNF.