Home Health & Hospice Week

                                                                        OMB Approval No. xxxx-xxxx    {Insert logo here}     NOTICE OF MEDICARE PROVIDER NON-COVERAGE   Patient Name:                                                                                                   Medicare Number:   THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type}
SERVICES WILL END:  {insert effective date}                 Your provider has determined that Medicare probably will not pay for your current {insert type} services after the effective date indicated above.         You may have to pay for any {insert type} services you receive after the above date.    
 YOUR RIGHT TO APPEAL THIS DECISION           You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services.           If you choose to appeal, the independent reviewer will ask for your opinion.  The reviewer will also 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 that services should no longer be covered after the effective date indicated above, Medicare will not 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 above.   The QIO will notify you of its decision as soon as possible, generally by no later than two days after the effective date of this notice.           Call your QIO at:  {insert name and number of QIO} to appeal, or if you have questions.   See the back of this notice for more information.                 OTHER INFORMATION:             Contact 1-800-MEDICARE (1-800-633-4227), or TTY/TDD:  1-877-486-2048 for more information about the appeals process.     ADDITIONAL INFORMATION (OPTIONAL)                      
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