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Run: NOMNC Notice of Medicare Non-Coverage Tracking

Track whether each NOMNC was issued on time, delivered correctly, and acknowledged before Medicare Part A services ended. Use it to catch late notices, missi...

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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 critical (required)

Record the date and time Medicare Part A coverage is scheduled to end.

Note (optional)

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 critical (required)

Verify the notice was delivered no later than 2 calendar days before the Medicare Part A end date.

Yes No N/A

Notice date matches documented issuance date critical (required)

Confirm the date on the NOMNC matches the date recorded in the medical record or tracking log.

Yes No N/A

Delivery method documented critical (required)

Select how the NOMNC was delivered.

Note (optional)

Receipt and Acknowledgment

Signed receipt or acknowledgment on file critical (required)

Verify a signed NOMNC receipt, acknowledgment, or equivalent proof of delivery is present in the record.

Yes No N/A

If signature unavailable, refusal or alternate delivery documentation present critical (required)

Confirm the file contains documentation explaining why a signature is not available, such as refusal, inability to sign, or alternate delivery process.

Yes No N/A

Receipt date aligns with notice delivery date critical (required)

Confirm the signed receipt or acknowledgment date is consistent with the documented delivery date.

Yes No N/A

Resident and Representative Notification

Resident or authorized representative identified critical (required)

Verify the chart identifies who received the NOMNC: resident, legal representative, or authorized representative.

Yes No N/A

Appeal rights and QIO contact information provided critical (required)

Confirm the notice includes appeal rights and Quality Improvement Organization contact information as required.

Yes No N/A

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.

Yes No N/A

Recordkeeping and Closeout

NOMNC copy retained in the medical record critical (required)

Confirm a copy of the completed NOMNC is filed in the resident record or designated tracking system.

Yes No N/A

Tracking log updated with issuance and receipt status critical (required)

Verify the facility tracking log reflects the notice date, delivery status, receipt status, and Part A end date.

Yes No N/A

Deficiency or corrective action required

Select the outcome of this review.

Note (optional)

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