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Home Health & Hospice Week

Patient Rights:

NEMB EXCEPTIONS GIVE HHAS BREATHING ROOM

Published on Thu Jul 08, 2004

While the Centers for Medicare & Medicaid Services claims home health agencies will have to issue NEMBs every time services are reduced or terminated, that's not strictly the case.

In supporting paperwork for the proposed notice of exclusions from Medicare benefits, CMS reveals a number of exceptions to the rule.

"The positive news is that there are instances when agencies will terminate services and will have no obligation to provide notice," notes Burtonsville, MD-based health care attorney Elizabeth Hogue. "There are appropriate exceptions included in the instructions for use of the forms."

Those exceptions include when:

  • the service may be denied as "not reasonable and necessary" ("medical necessity");
  • the service may be denied as "custodial care";
  • the patient does not need intermittent skilled nursing;
  • the patient is not confined to the home;
  • the hospice patient is found not to be terminally ill;
  • the patient received a prohibited telephone solicitation known as a "cold call" (durable medical equipment and supplies);
  • the supplier does not have a supplier number ( DME and supplies denials); and
  • the supplier has not obtained a required advance coverage determination (DME and supplies denials).

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