Form Instructions
Notice of Medicare Provider Non-Coverage
“The Generic Notice”
CMS-10123
A Medicare provider must give a completed copy of this notice to beneficiaries receiving services from skilled nursing facilities (SNFs), home health agencies (HHAs), comprehensive outpatient rehabilitation facilities (CORFs), or hospice not later than 2 days before the termination of services. This notice fulfills the requirement at 42 CFR §405.1200(b).
This is a standardized notice. Providers may not deviate from the content of the form except where indicated. (You may modify the form for mass printing to indicate the kind of service being terminated if only one type of service is provided, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation, or hospice.) Please note that the OMB control number must be displayed on the notice.
Providers will note that the notice must be validly delivered. Valid delivery means that the beneficiary must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The beneficiary must be able to understand that he or she may appeal the termination decision. If the beneficiary is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative. Valid delivery does not preclude the use of assistive devices, witnesses, or interpreters for notice delivery. Thus, if a beneficiary is able to comprehend the notice, but either is physically unable to sign it, or needs the assistance of an interpreter to translate it or an assistive device to read or sign it, valid delivery may be achieved by documenting the use of such assistance. Furthermore, if the beneficiary refuses to sign the notice, the notice is still valid as long as the provider documents that the notice was given, but the beneficiary refused to sign.
Notice Delivery to Representatives
CMS requires that notification of changes in coverage for a beneficiary who is not competent be made to a representative acting on behalf of the beneficiary. Notification to the representative may be problematic because he or she may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary is incapable or incompetent, and the provider cannot obtain the signature of the beneficiary’s representative through direct personal contact.
If the provider is unable to personally deliver a notice of noncoverage to a person legally acting on behalf of a beneficiary, then the provider should telephone the representative to advise him or her when the beneficiary’s services are no longer covered.
The beneficiary's appeal rights must be explained to the representative, and the name and telephone number of the appropriate quality improvement organization (QIO) should be provided.
The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date.
Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called.
When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested.
The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date of receipt.
When notices are returned by the post office, with no indication of a refusal date, then the beneficiary's liability starts on the second working day after the provider's mailing date.
These procedures also may be used where a beneficiary has authorized or appointed an individual to act on his or her behalf, and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact.
INSTRUCTIONS FOR CMS-10123 PAGE 1:
Logo: Providers may be identified in this space. Providers may elect to place their logo in this space. 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.
Patient Name: Insert the patient’s full name.
Patient Identification 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.
Title--{insert type}: Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation services, or hospice into the title.
THE EFFECTIVE DATE COVERAGE OF YOUR CURENT {INSERT TYPE} SERVICES WILL END: {Insert Effective Date}: Fill in the type of services ending, {home health, skilled nursing, comprehensive outpatient rehabilitation services, or hospice}and the actual date the covered service will end. The date should be in no less than 12-point type. Note that if the effective date for the service termination changes after delivery of the notice, the provider may contact the patient or representative by phone to inform him or her of the new service termination date. Confirm the telephone contact by written notice mailed on that same date.
YOUR RIGHT TO APPEAL THIS DECISION
Bullet # 1 N/A
Bullet # 2 N/A
Bullet # 3 N/A
Bullet # 4 N/A
Bullet # 5 N/A
HOW TO ASK FOR AN IMMEDIATE APPEAL
Bullet # 1 N/A
Bullet # 2 N/A
Bullet # 3 N/A
Bullet # 4 Insert the name and telephone numbers (including TTY) of the applicable QIO in no less than12-point type.
INSTRUCTIONS FOR CMS-XXXXX-X PAGE 2:
OTHER APPEAL RIGHTS
Bullet #1 N/A
Bullet #2 N/A
ADDITIONAL INFORMATION (OPTIONAL)
This space is available, at the option of the provider, to furnish additional relevant information to the beneficiary, such as further details about the reason for the service termination, or the timing of any additional liability risk. The use of this space does not replace the requirement to provide the Detailed Explanation of Non-Coverage to either the beneficiary or the QIO when an appeal is filed.
Signature line: The beneficiary or the representative must sign this line.
Date: The beneficiary or the representative must fill in the date that he or she signs the document.
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 once it has been completed is 10 minutes per notice, including the time to select the preprinted form, complete it 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.
| File Type | application/msword |
| File Title | Form Instructions |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2008-02-15 |
| File Created | 2008-02-15 |