OMB control number
Fast Appeals Notices: NOMNC/DENC (CMS-10123/10124)
OMB 0938-0953 · HHS/CMS.
OMB 0938-0953
The Notice of Medicare Provider Non-Coverage (CMS-10123) is used to inform fee-for-service Medicare beneficiaries of the determination that their provider services will end, and of their right to an expedited review of that determination. The Detailed Explanation of Non-Coverage (CMS-10124) is used to provide beneficiaries who request an expedited determination with detailed information of why the services should end.
The latest form for Fast Appeals Notices: NOMNC/DENC (CMS-10123/10124) expires 2027-11-30 and is listed under ICR 202407-0938-011.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 NOMNC-DENC_supportingstatement_2024_.docx | Supporting Statement A |
 NOMNC_2024_Crosswalk_508.pdf | Supplementary Document |
 Notice of Provider Non-Coverage (CMS-10123) |
Instruction |
| Detailed Explanation of Non-Coverage (CMS-10124) |
Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202407-0938-011 | Revision of a currently approved collection | 2024-08-07 | ||
| 202012-0938-012 | Extension without change of a currently approved collection | 2020-12-29 | ||
| 201711-0938-006 | Extension without change of a currently approved collection | 2017-11-27 | Approved with change | |
| 201409-0938-007 | Revision of a currently approved collection | 2014-09-16 | Approved without change | |
| 201112-0938-003 | No material or nonsubstantive change to a currently approved collection | 2011-12-14 | Approved without change | |
| 201108-0938-004 | Reinstatement with change of a previously approved collection | 2011-08-25 | Approved with change | |
| 200805-0938-009 | Revision of a currently approved collection | 2008-05-19 | Approved with change | |
| 200505-0938-004 | New collection (Request for a new OMB Control Number) | 2005-05-11 | Approved with change |
OMB Details
Notice of Provider Non-Coverage (CMS-10123)
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10123 | Notificación de Medicare de No-Cobertura (NOMNC) [Spanish] | Fillable Printable | Form |
| Form CMS-10123 | Notice of Medicare Non-Coverage (NOMNC) [English] | Fillable Printable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.