Notice of Medicare Non-Coverage
The Effective Date Coverage of Your Current Home Health Services Will End:________________________________
- Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current home health services after the effective date indicated above.
- You may have to pay for any services you receive after the above date.
Right to Appeal This Decision
- You have the right to an immediate, independent
medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the
- If you choose to appeal, the independent
reviewer will ask for your opinion. The
reviewer also will look at your medical records and/or other relevant
information. You do not have to prepare
anything in writing, but you have the right to do so if you wish.
- If you choose to appeal, you and the independent
reviewer will each receive a copy of the detailed explanation about why your
coverage for services should not continue.
You will receive this detailed notice only after you request an appeal.
- If you choose to appeal, and the independent
reviewer agrees services should no longer be covered after the effective date
Medicare nor your plan will pay for these services after that date.
- If you stop services no later than the effective
date indicated above, you will avoid financial liability.
How to Ask For an Immediate Appeal
- You must make your request to your Quality
Improvement Organization (also known as a QIO).
A QIO is the independent reviewer authorized by Medicare to review the
decision to end these services.
- Your request for an immediate appeal should be
made as soon as possible, but no later than noon of the day before the effective date indicated
- The QIO will notify you of its decision as soon
as possible, generally no later than two days after the effective date of this
notice if you are in Original Medicare. If
you are in a Medicare health plan, the QIO generally will notify you of its decision by the effective date
of this notice.
- Call your QIO at: KEPRO 1-888-319-8452 (TTY-855-843-4776) to appeal, or if you have questions.
If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights:
- If you have Original Medicare: Call the QIO listed.
- If you belong to a Medicare health plan: Call your plan at the number given below.
Plan contact information:
Additional Information (optional):
Please sign below to indicate you received and understood this notice.
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Representative__________________________________