Provider Procedural Manual - The Health Plan

PROVIDER PROCEDURAL MANUAL 2014NOTICE OF MEDICARE NON-COVERAGE(NOMNC)When The Health Plan has, for a Medicare Advantage member, authorized coverage of aninpatient admission or the admission was an emergency or urgently needed care, the memberremains entitled to inpatient hospital care until he/she receives a Notice of Discharge andMedical Appeal Rights (NOMNC), formerly known as the Notice of Non-Coverage.Physician’s concurrence with the notice is required.A member who wishes to appeal the determination made by The Health Plan that in-patient careis no longer medically necessary must request an immediate review by the Peer ReviewOrganization (PRO) of the determination. The member must request the immediate PRO reviewby noon of the first working day after receipt of the notice. The member will not be financiallyresponsible for the hospital care until the PRO makes its decision. If the admission was notauthorized by The Health Plan or the admission did not constitute emergency or urgently neededcare and the PRO upholds The Health Plan’s determination, the member is financiallyresponsible for the hospital costs.A member who fails to request immediate PRO review may request expedited reconsideration byThe Health Plan through the Appeal Process.COORDINATION OF BENEFITSMEDICARE ADVANTAGE SECONDARY PAYERMedicare Advantage is not always the primary payer for health insurance claims. The HealthPlan will comply with CMS’s requirement to provide information pertaining to claims in whichthe Medicare Advantage is secondary.Medicare Advantage is the secondary payer where the beneficiary is entitled to Veterans benefits,workers compensation, black lung benefits, or employer group coverage based on the MedicareSecondary Payer Guidelines. Click here to see Product Matrix for sample of Member ID Card.Section 3 / Page 16