CMS Pub. 100-04, ch. 30, § 260.5.3

The QIO must validate that the NOMNC included the required elements outlined below:

• Date that coverage of services ends.

• Date that beneficiary’s financial liability begins.

• Description of right to an expedited determination (and how to request an

expedited determination) and the right to submit relevant information to the QIO.

• Right to detailed information on why the provider believes Medicare will no

longer cover services.

• Contact information for QIO in the state where services were delivered.

The QIO should determine that NOMNC delivery was valid if all of the following criteria

are met:

• All elements stated above are included.

• The beneficiary signed and dated the notice. If the NOMNC was annotated

because the beneficiary refused to sign the notice upon delivery, the QIO may still

conduct an expedited determination in these instances.

• Notice was delivered at least two days before services terminate. For a non-residential provider, the notice may be delivered at the next to last visit before

services terminate.

Invalidating a NOMNC should be a rare occurrence. The only reasons to invalidate are

the lack of one of the criteria stated above or a pattern of minor errors as established by

the provider.

If a QIO invalidates a NOMNC, a new NOMNC must be issued to the beneficiary with

an effective date at least two days after the beneficiary receives valid notice. If the

beneficiary again disagrees with the termination of care, a new request to the QIO must

be made.