Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

BCN Advantage^SM and Medicare Plus Blue^SM PPO members sometimes remain in skilled nursing facilities for days beyond the service end date on the Notice of Medicare Non-Coverage form. Sometimes the extended stay is due to a provider's failure either to deliver a completed NOMNC form in a timely manner or to comply with guidelines from Livanta, LLC, the quality improvement organization. This results in days added to the member's stay that may not be medically necessary.

On behalf of Blue Cross Blue Shield of Michigan, naviHealth will issue an administrative denial for these days if they occur because the SNF provider didn't handle the NOMNC in accordance with the Centers for Medicare and Medicaid Services guidelines. In an administrative denial, the authorization is approved but the reimbursement for the extra days is denied.

Examples of improper handling and delivery of the NOMNC include:

• Late delivery of the NOMNC. Members must receive the NOMNC 48 hours prior to the planned discharge date.
  
  Note: naviHealth completes as much of the NOMNC as possible and tells the provider when to issue the NOMNC.

• Failure to fill out the NOMNC in its entirety. All fields in the NOMNC must be completed, including all date and signature fields. For more information, see the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123*.
• Not submitting the requested medical information to the QIO in a timely manner, when the member appealed the service end date with the QIO

Note: To view CMS instructions about appropriate delivery of the NOMNC, see sections 260.2 to 260.4.5 of the CMS Manual System: Pub 100-04 Medicare Claims Processing, Transmittal 2711.*

When SNF providers have repeated difficulties handling the NOMNC according to CMS guidelines, their naviHealth care coordinators will reach out to provide education about CMS guidelines and health plan requirements. If, after receiving education, a SNF provider continues to have difficulties, naviHealth will deliver an administrative denial letter to the provider when members stay beyond the end date stated on the NOMNC.

The administrative denial letter will include details on the specific CMS guideline violations. Blue Cross and Blue Care Network will hold the provider responsible for the additional days the member stayed in the SNF. Per CMS guidelines, providers can't bill members for the additional days.

You can find information about CMS guidelines and Medicare Plus Blue and BCN Advantage requirements in the following locations.

• Medicare Claims Processing Manual, Chapter 30*: See section "260.3.6 - Financial Liability for Failure to Deliver a Valid NOMNC."
• Medicare Plus Blue PPO Manual: See the Utilization Management section. Look under the "Post-acute care skilled nursing, inpatient rehabilitation and long-term acute care facilities" heading.
• BCN Provider Manual: See the BCN Advantage chapter. Look in the "BCN Advantage provider appeals" section.

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.