CMS-10124 Detailed Explanation of Non-coverage

OMB Approval No. 0938-0953

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DETAILED EXPLANATION OF [Insert type] NON-COVERAGE

Date:

Patient Name: Patient ID Number:

This notice gives a detailed explanation of why your provider has determined that Medicare coverage for your current {insert type} services should end. This notice is not the decision on your appeal. The decision on your appeal will come from your Quality Improvement Organization (QIO).

We have reviewed your case and decided that Medicare coverage of your current {insert type} services should end.

• The facts used to make this decision:

• Detailed explanation of why these services are no longer covered, and the specific Medicare coverage rules and policy used to make this decision:

If you would like a copy of the policy or coverage guidelines used to make this decision, or a copy of the documents sent to the QIO, please call us at {insert provider telephone number}:

Form No. CMS-10124 Exp. Date xx/xx/xxxx

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 distribute this information collection is 1 hour per notice, including the time to select the preprinted form, gather the needed information, complete the form, and deliver it 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, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.