FFS & MA NOMNC/DENC

What's New

11/18/2024: The Office of Management and Budget (OMB) has renewed the Notice of Medicare Non-Coverage (NOMNC, CMS-10123), and the Detailed Explanation of Non-Coverage (DENC, CMS-10124). Please note the NOMNC and DENC renewed notices contain updates which are applicable only to Medicare Advantage enrollees (see below). Providers must use the current notices until December 31, 2024, and are required to use the new NOMNC and DENC beginning January 1, 2025. 

The updated notices, including Spanish versions, are available in the "Downloads" section below. 

Medicare Advantage Only

The NOMNC has been modified to reflect regulations providing enrollees additional fast-track appeal rights when they untimely request an appeal to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or still wish to appeal after they end services on or before the planned termination date.  (See: CMS-4205-F, p. 30827.)  

Additionally, DENC instructions have been updated to include a new element for health plans to complete for the DENC: 
Special instructions for repeat appeals within the same episode of care:
If the enrollee has previously received a favorable BFCC-QIO appeal decision during the current episode of care, detail the specific change(s) in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.
 

HHAs, SNFs, Hospices, and CORFs are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending.  The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO.  A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination.  The DENC explains the specific reasons for the end of covered services.

• To download the NOMNC and DENC, please click on the appropriate link below in "Downloads".
• Full instructions for the Original Medicare, also known as Fee for Service (FFS), expedited determination process are available in Section 260, of Chapter 30 of the CMS Claims Processing Manual, available below in "Downloads".
• Full instructions for the Medicare health plan expedited determination process, also known as the Medicare Advantage (MA) fast track appeals process, are available in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in Section 100, available below in "Downloads."

Questions?

Questions regarding the NOMNC and DENC can be submitted at: https://appeals.lmi.org