Form CMS 10123-NOMNC – Fill Out and Use This PDF

Provider Name:_______________ Address/Phone:___________________________________

Notice of Medicare Non-Coverage

Patient name: _____________________________ Patient number: ______________

The Effective Date Coverage of Your Current ________________________ (insert type)

Services Will End: ______________ (insert effective date)

•Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current ____________________ (insert type) services after the effective date indicated above.

•You may have to pay for any services you receive after the above date.

Your Right to Appeal This Decision

•You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal.

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

•If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal.

•If you choose to appeal, and the independent reviewer agrees services should no longer be covered after the effective date indicated above;

o Neither Medicare nor your plan will pay for these services after that date.

•If you stop services no later than the effective date indicated above, you will avoid financial liability.

How to Ask For an Immediate Appeal

•You must make your request to your Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). A BFCC-QIO is the independent reviewer authorized by Medicare to review the decision to end these services.

•Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.

•The BFCC-QIO will notify you of its decision as soon as possible, generally no later than two days after the effective date of this notice if you are in Original Medicare. If you are in a Medicare health plan, the BFCC-QIO generally will notify you of its decision by the effective date of this notice.

•Call your BFCC-QIO at: Livanta, 1- 866-815-5440, TTY: 1-866-868-2289, to appeal, or if you have questions.

See page 2 of this notice for more information.

Form CMS 10123-NOMNC (Approved 12/31/2011)

OMB approval 0938-0953