NOMNC Notice of Medicare Non-Coverage Tracking

Inspection template for nursing facilities to verify that the Notice of Medicare Non-Coverage (NOMNC) was issued on time, delivered to the resident or representative, and supported by a signed receipt on file before Medicare Part A services ended.

Inspection Details

• Resident or case identifier recorded
  Enter the resident chart number, encounter ID, or other internal case identifier used to track the NOMNC event.
• Medicare Part A end date documented
  Record the date and time Medicare Part A coverage is scheduled to end.
• Inspector review date recorded
  Record the date and time this tracking review was completed.

NOMNC Issuance Timing

• NOMNC issued at least 2 calendar days before Part A end
  Verify the notice was delivered no later than 2 calendar days before the Medicare Part A end date.
• Notice date matches documented issuance date
  Confirm the date on the NOMNC matches the date recorded in the medical record or tracking log.
• Delivery method documented
  Select how the NOMNC was delivered.

Receipt and Acknowledgment

• Signed receipt or acknowledgment on file
  Verify a signed NOMNC receipt, acknowledgment, or equivalent proof of delivery is present in the record.
• If signature unavailable, refusal or alternate delivery documentation present
  Confirm the file contains documentation explaining why a signature is not available, such as refusal, inability to sign, or alternate delivery process.
• Receipt date aligns with notice delivery date
  Confirm the signed receipt or acknowledgment date is consistent with the documented delivery date.

Resident and Representative Notification

• Resident or authorized representative identified
  Verify the chart identifies who received the NOMNC: resident, legal representative, or authorized representative.
• Appeal rights and QIO contact information provided
  Confirm the notice includes appeal rights and Quality Improvement Organization contact information as required.
• Resident or representative questions documented and addressed
  Verify any questions, concerns, or follow-up communication about the non-coverage notice are documented in the record.

Recordkeeping and Closeout

• NOMNC copy retained in the medical record
  Confirm a copy of the completed NOMNC is filed in the resident record or designated tracking system.
• Tracking log updated with issuance and receipt status
  Verify the facility tracking log reflects the notice date, delivery status, receipt status, and Part A end date.
• Deficiency or corrective action required
  Select the outcome of this review.