Form Instructions
“Detailed Explanation of {Insert Type} Non-Coverage” CMS-10124
A Medicare provider must furnish a completed copy of this notice to beneficiaries receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility and hospice services upon notice from the Quality Improvement Organization (QIO) that the beneficiary has appealed the termination of services in these settings. This notice fulfills the requirement at 42 CFR 405.1202(f)(1), and must be provided no later than close of business of the day of the QIO’s notification.
This is a standardized notice. Providers may not deviate from the content of the form except where indicated. Please note that the OMB control number must be displayed on the notice.
Insert logo here: Not required. Providers may elect to place their logo in this space. The name and address of the provider must be immediately under the logo, if not incorporated into the logo. If no logo is used, the name and address and telephone number of the provider must appear above the title of the form.
Title--{insert type}: Insert the kind of service being terminated into the title, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation, or hospice services.
Date: Fill in the date the notice is generated by the provider.
Patient Name: Fill in the beneficiary’s full name
Patient ID Number: Providers may use a number that helps to link the notice with a related claim when applicable. This field is optional and choosing not to enter a number will not invalidate the notice.
{Insert type} – Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation, or hospice.
Bullet # 1 The facts used to make this decision: Fill in the patient-specific information that describes the current functioning and progress of the beneficiary with respect to the services being provided. Use full sentences in plain English.
Bullet # 2 The detailed explanation of why the services are no longer covered under Medicare: Fill in the detailed and specific reasons why services are no longer reasonable or necessary for the beneficiary or no longer covered according to the Medicare coverage guidelines. Describe how the beneficiary does not meet these guidelines.
If you would like a copy of the policy: If the provider has not supplied the Medicare guidelines or policy used to decide the termination date, inform the beneficiary of how and where to obtain the policy. The provider should supply a telephone number for beneficiaries to get a copy of the relevant documents sent to the QIO.
Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0953. The time required to collect and distribute this information collection is 1 hour per appeal request, including the time to select the preprinted form, prepare the complete case file and mail it to the QIO. The provider must also mail a copy of the completed form to the beneficiary. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, Attn: PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
| File Type | application/msword |
| File Title | Form Instructions |
| Author | Chris Gayhead |
| Last Modified By | CMS |
| File Modified | 2008-02-15 |
| File Created | 2008-02-15 |