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.
Download FFS Expedited Determination Notices and Instructions
To download the FFS Expedited Determination Notices and Instructions, please click on the appropriate link below.
March 2012 Update
Issuance of revised NOMNC and DENC, FORM CMS-10123 and CMS-10124
CMS is issuing a new combined Notice of Medicare Non-Coverage. This notice will replace the CMS 10123 (Original Medicare notice) and the CMS 10095 (Medicare Advantage notice).
This combined notice retains the form number of the current Original Medicare Notice (CMS 10123) and the name of the MA notice (Notice of Medicare Non-Coverage, or NOMNC).
CMS also is issuing a new Detailed Explanation of Non-Coverage, or DENC, with the form number CMS 10124.
Providers are required to issue the new combined notices as soon as possible, but no later than May 1, 2012.
- UPDATED - Notice of Medicare Non-Coverage (NOMNC) - English and Spanish [ZIP, 68KB]
- UPDATED - Instructions for Notice of Medicare Non-Coverage [PDF, 52KB]
- UPDATED - Detailed Explanation of Non-Coverage (DENC) - English and Spanish [ZIP, 87KB]
- UPDATED - Instructions for Detailed Explanation of Non-Coverage [PDF, 26KB]
- FFS Expedited Review Generic Notice CMS10123 in MSWord [ZIP, 7KB]
- Generic Notice CMS10123 Instructions [PDF, 30KB]
- FFS Expedited Review Detailed Notice CMS10124 in MS Word [ZIP, 5KB]
- Detailed Notice CMS10124 Instructions [PDF, 18KB]
- Expedited Review General Information [PDF, 22KB]
- Page last Modified: 04/10/2013 11:11 AM
- Help with File Formats and Plug-Ins