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FFS ED Notices

HHAs, SNFs, Hospices, and CORFs are required to provide a Generic Notice to beneficiaries to alert them that Medicare covered item(s) and/or service(s) are ending and give beneficiaries the opportunity to request an expedited determination from a QIO.  A Detailed Notice is given when the QIO review is requested in order to provide more explanation on why coverage is ending.

To download the FFS Expedited Determination Notices and Instructions, please click on the appropriate link below.

September 30, 2011: IMPORTANT UPDATE ON STATUS OF THE REVISED NOMNC and DENC, FORM CMS-10123 and CMS-10124

The Notice of Medicare Non-Coverage CMS-10123 (formerly the Notice of Medicare Provider Non-Coverage) and the Detailed Explanation of Non-Coverage CMS-10124 are currently in the final stages of the Office of Management and Budget (OMB) review in accordance with the Paperwork Reduction Act (PRA). OMB issued an extension of the expiration date on the current notices pending approval of the revised forms.

Providers should continue using the existing notices until final OMB approval at which time it will be posted on our website along with the date for its mandatory use.

 

Downloads

FFS Expedited Review Generic Notice CMS10123 in MSWord [zip. 8kb]

Generic Notice CMS10123 Instructions [pdf, 33kb]

FFS Expedited Review Detailed Notice CMS10124 in MS Word [zip, 5kb]

Detailed Notice CMS10124 Instructions [pdf, 14kb]

General Information [PDF, 22kb]

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Page Last Modified: 09/30/2011 1:31:21 PM
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