CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English]

{Insert provider contact information here} Notice of Medicare Non-Coverage

Patient name: Patient number:

Medicare Coverage of Your Current {insert type} Services Will End on {insert effective date}

Your provider and/or health plan determined that Medicare probably won’t pay for your {insert type} services after the above date. You may have to pay for any services you get after this date.

Your right to appeal this decision

• You have the right to appeal the decision to end Medicare coverage of your services. This means you’ll get an independent medical review right away. Your services will continue during the appeal.

• If you choose to appeal, the independent reviewer will ask for your opinion. You don’t have to prepare anything in writing, but you have the right to do so. The reviewer also will look at your medical records and/or other relevant information.

• Once you ask for an appeal, you’ll get a notice with a detailed explanation about why your service coverage should end.

• If the independent reviewer agrees Medicare coverage for your services should end, neither Medicare nor your plan will pay for these services after the above date.

• If you stop services by the above date, you’ll avoid financial liability.

How to ask for an immediate appeal

• Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date.

• Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare.

• If you miss the deadline to ask for an immediate appeal, you still have appeal rights.

• Call your QIO at {insert QIO name and toll-free number of QIO} to appeal, or if you have questions.

What happens next

• The QIO will let you know its decision as soon as possible, generally no later than two days after the effective date above. If you’re in a Medicare health plan, the QIO generally will let you know its decision by the effective date above.

• Call your QIO at {insert QIO name and toll-free number of QIO} to learn more.

Additional information (optional):

Sign below to show you received and understand this notice.

I’ve been notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO.

Signature of Patient or Representative Date

You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633- 4227) for more information. TTY users can call 1-877-486-2048.

Form CMS 10123-NOMNC

OMB approval 0938-0953 Exp. xx-xx-20xx