Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202

Form Instructions for the Notice of Medicare Non-Coverage
(NOMNC) CMS-10123
When to Deliver the NOMNC
A Medicare provider or health plan must give an advance, completed copy of the Notice
of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving skilled
nursing, home health (including psychiatric home health), comprehensive outpatient
rehabilitation facility, and hospice services, no later than two days before the termination
of services. This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and
42 CFR 422.624(b)(1) and (2). In situations where the termination decision is not
delegated to a provider by a health plan, the plan must provide the service termination
date to the provider not later than two days before the termination of services for timely
delivery to occur.
Valid Notice Delivery
The notice must be validly delivered. Valid delivery means that the beneficiary/enrollee
must be able to understand the purpose and contents of the notice in order to sign for
receipt of it. The beneficiary/enrollee must be able to understand that he or she may
appeal the termination decision. If the beneficiary/enrollee 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/enrollee is not able to physically sign the
notice to indicate receipt, then delivery may be proven valid by other means.
Valid delivery also requires delivery of an Office of Management and Budget (OMB) approved notice consistent with either the standardized OMB-approved original notice
format.
In general, notices are valid when all patient specific information required by the notice
is included, and any non-conformance is minor; that is, the non-conformance does not
change the meaning of the notice or the ability to request an appeal. For example,
misspelling the word “health” is a minor non-conformance of the notice that would not
invalidate the notice. However, a transposed phone number on the notice would not be
considered a minor non-conformance since the beneficiary/enrollee would not be able
to contact the QIO to file an appeal. Errors brought to the attention of the provider or
plan should also be reported to the appropriate regional office staff member.

Form Instructions 10123-NOMNC

OMB Approval 0938-xxxx

Notice Delivery to Incompetent Beneficaries/Enrollees in an Institutionalized
Setting
CMS requires that notification of changes in coverage for an institutionalized
beneficiary/enrollee who is not competent be made to a representative. Notification to
the representative may be problematic because that person may not be available in
person to acknowledge receipt of the required notification. Providers are required to
develop procedures to use when the beneficiary/enrollee is incapable or incompetent,
and the provider cannot obtain the signature of the enrollee’s representative through
direct personal contact. If the provider is personally unable to deliver a NOMNC to a
person acting on behalf of an enrollee, then the provider should telephone the
representative to advise him or her when the enrollee’s services are no longer covered.
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. 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. Place a dated copy of the notice in the
enrollee’s medical file. When notices are returned by the post office with no indication
of a refusal date, then the enrollee’s liability starts on the second working day after the
provider’s mailing date.
Special Circumstances
Do not use the NOMNC if coverage is being terminated for any of the following reasons:
•
•
•
•

Because the Medicare benefit is exhausted;
For denial of Medicare admission;
For denial of services that is not a Medicare benefit; or
Due to a reduction or termination of a Medicare service that does not end the
skilled Medicare stay.

Health Plans only; in these cases, the plan must issue the CMS form 10003 - Notice of
Denial of Medical Coverage (NDMC).
Modifications to the NOMNC
The NOMNC is a standardized notice. Therefore, plans and providers may not re-write,
re-interpret, or insert non-OMB-approved language into the body of the notice except
where indicated. Without CMS regional office approval, however, you may modify the
notice for mass printing to indicate the kind of service being terminated if only one type
of service is provided by the facility; that is, skilled nursing, home health, or
comprehensive outpatient rehabilitation facility. You may also modify the form to
reference the kind of plan issuing the notice. Notices may not be highlighted or
shaded. Additionally, text must be no less than 12-point type, and the background
must be high contrast. Please note that the CMS form number and the OMB control
number must be displayed on the notice.

Form Instructions 10095-NOMNC

OMB Approval 0938-0910

Substantive modifications, such as wrapping a letter format around the notice, may not
be adopted without regional office approval. Regional office approval must be obtained
for each modification not described in these instructions or other CMS guidance. Plans
should contact their CMS regional office for additional questions regarding
modifications to the notice.
Heading
Contact information: The name, address and toll-free number of the provider that
delivers the notice must appear above the title of the form. The provider’s registered
logo may be used.
Member number: Providers may fill in the enrollee’s unique medical record or other
identification number. Note that the enrollee’s HIC number must not be used.
THE EFFECTIVE DATE YOUR {INSERT TYPE} SERVICES WILL END: {Insert
Effective Date}: Fill in the type of services ending, {home health, skilled nursing, or
comprehensive outpatient rehabilitation services} and the actual date the service
will end. Note that the date should be in no less than 12-point type. If handwritten,
notice entries must be at least as large as 12- point type and legible.
YOUR RIGHT TO APPEAL THIS DECISION
Bullet # 1

not applicable

Bullet # 2

not applicable

Bullet # 3

not applicable

Bullet # 4

not applicable

Bullet # 5

not applicable

HOW TO ASK FOR AN IMMEDIATE APPEAL
Bullet # 1

not applicable

Bullet # 2

not applicable

Bullet # 3

not applicable

Bullet # 4 Insert the name and telephone numbers (including TTY) of the applicable
QIO in no less than12-point type.

Form Instructions 10095-NOMNC

OMB Approval 0938-0910

Signature page:
Plan contact information: The plan’s name and contact information must be displayed
here for the enrollee’s use in case an expedited appeal is requested or in the event the
enrollee or QIO seeks the plan’s identification.
Optional: Additional information. This section provides space for additional
pertinent information that may be useful to the enrollee. It may not be used as a
Detailed Explanation of Non-Coverage, even if facts pertinent to the termination
decision are provided.
Signature line: The enrollee or the representative must sign this line.
Date: The enrollee or the representative must fill in the date that he or she signs the
document. If the document is delivered, but the enrollee or the representative refuses
to sign on the delivery date, then annotate the case file to indicate the date that the
form was delivered.

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 0938-0910. The time required to complete this information collection is estimated
to average 15 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attention: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Form Instructions 10095-NOMNC

OMB Approval 0938-0910