DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA)

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

Form Instructions for the Detailed Explanation of Non-Coverage
(DENC)
CMS-10124

A Medicare provider or health plan (Medicare Advantage plans and cost plans,
collectively referred to as “plans”) must deliver a completed copy of this notice to
beneficiaries/enrollees receiving covered 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. The DENC must be provided no later than
close of business of the day of the QIO’s notification.
Alterations to the DENC
Providers may include their business logo and contact information on the top of the
DENC. Text may not be moved to a second page to accommodate large logos, address
headers, etc.

Heading
Insert contact information here: The name, address and telephone number of the
provider or plan that 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’s/enrollee’s first and last name.
Member number: Fill in the beneficiary’s/enrollee’s medical record or identification
number. The beneficiary’s/enrollee’s 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.

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 these
guidelines.
Form Instructions CMS-10124-DENC

Bullet # 3 (Plans only) 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 no longer
covered according to the plan’s policy guidelines, if applicable. Describe how the
enrollee does not meet these guidelines. If the plan relied exclusively on Medicare
coverage guidelines, please explain that here.
If you would like a copy of the policy: If the plan has not provided the Medicare
guidelines or policy used to decide the termination date, inform the beneficiary/enrollee
how and where to obtain the policy. Provide a telephone number for
beneficiaries/enrollees to get a copy of the relevant documents 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 0938-0953. 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