Notice of Provider Non-Coverage (CMS-10123)

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

A Medicare provider/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 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.

Alterations to the NOMNC: Providers/plans 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 provider 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.

Patient Name: Fill in the beneficiary’s/enrollee’s first and last name.

Patient number: Fill in the beneficiary’s/enrollee’s medical record or identification number. The beneficiary’s/enrollee’s MBI 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.

{Insert Effective Date}: Insert the actual date coverage of the service will end.

Signature and Date Line: The beneficiary/enrollee or representative must sign and date this line.

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 .166 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.

Instructions CMS-10123-NOMNC OMB Approval No. 0938-0953 Exp. xx-xx-20xx