Form CMMS-10124 Detailed Explanation of Non-coverage

Insert contact information here

Detailed Explanation of Non-coverage
Date:

Patient name:

Patient number:

This notice gives a detailed explanation of why your Medicare provider and/or health plan
has determined Medicare coverage for your current 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 your current services are no longer covered, and the
specific Medicare coverage rules and policy used to make this decision:

• Plan policy, provision, or rationale used in making the decision (health plans
only):

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/plan tollfree telephone number}

Form CMS-10124-DENC (Exp. xx/xx/2014)

OMB Approval No. 0938–xxxx