NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA)

OMB Control No. 0938-0953 (Expires: TBD)

Form Instructions for the Notice of Medicare Non-Coverage
(NOMNC) CMS-10123

When to Deliver the NOMNC
A Medicare provider or health plan (Medicare Advantage plans and cost plans ,
collectively referred to as “plans”) must deliver a completed copy of the Notice of
Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled
nursing, home health (including psychiatric home health), comprehensive outpatient
rehabilitation facility, and hospice services.
The NOMNC must be delivered at least two calendar days before Medicare covered
services end or the second to last day of service if care is not being provided daily.
Note: The two day advance requirement is not a 48 hour requirement.
This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR
422.624(b)(1) and (2). Additional guidance for Original Medicare and Medicare
Advantage can be found, respectively, at Chapter 4, Section 260 of the Medicare
Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare
Managed Care Manual.
Plans only:
In situations where the decision to terminate covered services is not delegated to a
provider by a health plan, but the provider is delivering the notice, the health plan must
provide the service termination date to the provider at least two calendar days before
Medicare covered services end.
Provider Delivery of the NOMNC
Providers must deliver the NOMNC to all beneficiaries/enrollees eligible for the
expedited determination process per Chapter 4, Section 260 of the Medicare Claims
Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care
Manual. A NOMNC must be delivered even if the beneficiary/enrollee agrees with the
termination of services. Medicare providers are responsible for the delivery of the
NOMNC. Providers may formally delegate the delivery of the notices to a designated
agent such as a courier service; however, all of the requirements of valid notice delivery
apply to designated agents.
The provider must ensure that the beneficiary/enrollee or representative signs and
dates the NOMNC to demonstrate that the beneficiary/enrollee or representative
received the notice and understands that the termination decision can be disputed. Use
of assistive devices may be used to obtain a signature.
Form Instructions 10123-NOMNC

Electronic issuance of NOMNCs is not prohibited. If a provider elects to issue a NOMNC
that is viewed on an electronic screen before signing, the beneficiary/enrollee must be
given the option of requesting paper issuance over electronic if that is what is preferred.
Regardless of whether a paper or electronic version is issued and regardless of whether
the signature is digitally captured or manually penned, the beneficiary/enrollee must be
given a paper copy of the NOMNC, with the required beneficiary/enrollee -specific
information inserted, at the time of electronic notice delivery.
Notice Delivery to Representatives
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 a beneficiary/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.
Exceptions
The following service terminations, reductions, or changes in care are not eligible for an
expedited review. Providers should not deliver a NOMNC in these instances.
•

When beneficiaries/enrollees never received Medicare covered care in
one of the covered settings (e.g., an admission to a SNF will not be
covered due to the lack of a qualifying hospital stay or a face-to-face visit
was not conducted for the initial episode of home health care).

•

When services are being reduced (e.g., an HHA providing physical
therapy and occupational therapy discontinues the occupational therapy).

•

When beneficiaries/enrollees are moving to a higher level of care (e.g.,
home health care ends because a beneficiary/enrollee is admitted to a
SNF).

Form Instructions 10123-NOMNC

•

When beneficiaries/enrollees exhaust their benefits (e.g., a
beneficiary/enrollee reaches 100 days of coverage in a SNF, thus
exhausting their Medicare Part A SNF benefit).

•

When beneficiaries/enrollees end care on their own initiative (e.g., a
beneficiary/enrollee decides to revoke the hospice benefit and return to
standard Medicare coverage).

•

When beneficiaries/enrollees transfer to other providers at the same level
of care (e.g., a beneficiary/enrollee transfers from one SNF to another
while remaining in a Medicare-covered SNF stay).

•

When a provider discontinues care for business reasons (e.g., an HHA
refuses to continue care at a home with a dangerous animal or because
the beneficiary/enrollee was receiving physical therapy and the provider’s
physical therapist leaves the HHA for another job).

Plans Only:
If a member requests coverage in the above situations, the plan must issue the CMS
form 10003 - Notice of Denial of Medical Coverage.

Alterations to the NOMNC
The NOMNC must remain two pages. The notice can be two sides of one page or one
side of two separate pages, but must not be condensed to one page.
Providers may include their business logo and contact information on the top of the
NOMNC. Text may not be moved from page 1 to page 2 to accommodate large logos,
address headers, etc.
Providers may include information in the optional “Additional Information” section
relevant to the beneficiary’s/enrollee’s situation.
Note: Including information normally included in the Detailed Explanation of NonCoverage (DENC) in the “Additional Information” section does not satisfy the
responsibility to deliver the DENC, if otherwise required.

Form Instructions 10123-NOMNC

Heading
Contact information: The name, address and telephone 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 beneficiary’s/enrollee’s unique medical
record or other identification number. The beneficiary’s/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,
comprehensive outpatient rehabilitation services, or hospice} 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.

Signature page:
Plan contact information (Plans only): 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.

Form Instructions 10123-NOMNC

Optional: Additional information. This section provides space for additional
pertinent information that may be useful to the beneficiary/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 beneficiary/enrollee or the representative must sign this line.
Date: The beneficiary/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 0938-0953. The time required to complete this information collection is
estimated to average 10 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 10123-NOMNC