Form CMS 10123-NOMNC at a glance
What it is: Form CMS 10123-NOMNC is the Notice of Medicare Non-Coverage.
Who signs: Sign on the Signature of Patient or Representative line to show you received and understand this notice.
A filled-in Form CMS 10123-NOMNC example: a patient signs the notice
How to fill out Form CMS 10123-NOMNC, box by box
Additional information (optional)
Add any Additional information (optional).
Sign below to show you received and understand this notice
Sign on the Signature of Patient or Representative line and enter the Date.
I've been notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO.
More rules for Form CMS 10123-NOMNC
Medicare coverage of your current services will end on the effective date. Your provider and/or health plan determined that Medicare probably won't pay for your services after the effective date. You may have to pay for any services you get after this date.
The QIO will let you know its decision as soon as possible, generally no later than two days after the effective date. If you're in a Medicare health plan, the QIO generally will let you know its decision by the effective date. Call your QIO to learn more.
If your situation is different
Your right to appeal this decision
You have the right to appeal the decision to end Medicare coverage of your services. This means you'll get an independent medical review right away. Your services will continue during the appeal. If you choose to appeal, the independent reviewer will ask for your opinion. You don't have to prepare anything in writing, but you have the right to do so. The reviewer also will look at your medical records and/or other relevant information. Once you ask for an appeal, you'll get a notice with a detailed explanation about why your service coverage should end. If the independent reviewer agrees Medicare coverage for your services should end, neither Medicare nor your plan will pay for these services after the effective date. If you stop services by the effective date, you'll avoid financial liability.
How to ask for an immediate appeal
Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the effective date. Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare. If you miss the deadline to ask for an immediate appeal, you may still have appeal rights. Call your QIO to appeal, or if you have questions.
Sources
[1] Form CMS 10123-NOMNC, Notice of Medicare Non-Coverage, Centers for Medicare & Medicaid Services (the Official source link on this page).