Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

Form Instructions for the Detailed Explanation of Non-Coverage
(DENC)
CMS-10124
A Medicare provider/health plan (“plan”) must provide a completed copy of this notice to
beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient
rehabilitation facility , and hospice services upon notice from the Quality Improvement
Organization (QIO) that the beneficiary/enrollee has appealed the termination of
services in these settings. This notice fulfills the requirements at 42 CFR 405.1202(f)(1)
and 42 CFR 422.626(e)(1), and must be provided no later than close of business of the
day of the QIO’s notification.
Do not use the DENC if coverage is being terminated for any of the following reasons:
• Because the Medicare benefit is exhausted;
• For denial of Medicare admission to a skilled nursing facility or comprehensive
outpatient rehabilitation facility or denial of Medicare home health services;
• For denial of a service that is not a Medicare benefit; or
• Due to a reduction or termination of a Medicare-covered service that does not
conclude 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).
The DENC is a standardized notice. Providers/plans may not deviate from the wording
or content of the form except where authorized to do so. Please note that the OMB
control number must be displayed in the upper right of the notice. Notice entries may
be typed or handwritten. Handwritten entries must be at least as large as 12-point type
and legible.
Heading
Insert contact information here: The name, address and toll-free number of the
provider or plan that actually delivers the notice must appear above the title of the form.
The entity’s registered logo is not required, but may be used.
Date: Fill in the date the notice is generated by the provider or plan.
Patient Name: Fill in the beneficiary/enrollee first and last name.
Member number: Fill in the beneficiary/enrollee medical record or identification
number. Note that the HIC number must not be used.
{Insert type} – Insert the kind of service being terminated, i.e., skilled nursing, home
health, comprehensive outpatient rehabilitation service, or hospice.

Form Instructions CMS-10124-DENC

OMB Approval No. 0938-xxxx

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/enrollee 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. Fill in
the detailed and specific reasons why services are either no longer reasonable or
necessary for the beneficiary/enrollee or are no longer covered according to the
Medicare guidelines. Describe how the beneficiary/enrollee does not meet any
applicable guidelines.
Bullet # 3
The plan policy, provision, or rationale used in the decision if the notice is
delivered to a health plan enrollee: Fill in the reasons services are either no longer
reasonable or necessary for the enrollee or are no longer covered according to the
plan’s policy guidelines. Describe how the enrollee does not meet these guidelines. If
the plan relied exclusively on Medicare coverage guidelines, please indicate so here.
If you would like a copy of the policy: Tell the beneficiary/enrollee how and where to
obtain a copy of the policy. The provider/plan should provide a toll-free number for
beneficiaries/enrollees to get a copy of the documents that were sent to the QIO.

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 1.25
hours 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(s) 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 CMS-10124-DENC

OMB Approval No. 0938-xxxx