Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
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 Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124) expires 2021-05-31 and can be found here.
Form CMS-10123 Notice of Provider Non-Coverage (CMS-10123)
CMS-10123 and 10124 SupportingStatement2020.docx
Notice of Provider Non-Coverage (CMS-10123) | Extension without change of a currently approved collection | 2020-12-29 | ||
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Approved with change |
Extension without change of a currently approved collection | 2017-11-27 | |
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Approved without change |
Revision of a currently approved collection | 2014-09-16 | |
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Approved without change |
No material or nonsubstantive change to a currently approved collection | 2011-12-14 | |
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Approved with change |
Reinstatement with change of a previously approved collection | 2011-08-25 | |
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Approved with change |
Revision of a currently approved collection | 2008-05-19 | |
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Approved with change |
New collection (Request for a new OMB Control Number) | 2005-05-11 |
Notice of Provider Non-Coverage (CMS-10123)
Federal Enterprise Architecture: Health - Health Care Services
| Form CMS-10123 | Notice of Medicare Non-Coverage (NOMNC) [English] | Fillable Printable | Form |
| Form CMS-10123 | Notificación de Medicare de No-Cobertura (NOMNC) [Spanish] | Fillable Printable | Form |
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