Non-participating Medicare Advantage providers can appeal decisions regarding payment. This appeal process applies to all of our medical benefits plans. (State requirements take precedence when they differ from our policy.)
We have a form you can use when you give Notice of Medicare non-coverage (NOMNC) to someone other than the member. Use this form to document such notice. You must give the NOMNC to the member or his/her appointed or authorized representative at least two calendar days before the date services will be terminated.
If the member files a fast track appeal with the Quality Improvement Organization (QIO), fax this form and a copy of the NOMNC letter to both: