Checklist for Issuing a Notice of Medicare Provider Non-Coverage
(Applies to Medicare Fee-For-Service Beneficiaries)
□ Correct form is used. Form should be CMS-10123, Exp. Date 06/20/2008. Download the final
version form at: www.cms.hhs.gov/medicare/bni/.
□ Heading is complete and accurate. Logos may be used if they include the name, address, and
phone number of the organization responsible for the termination decision.
□ The effective date that coverage will end has been inserted under the heading.
The notice should read, “The effective date coverage of your {insert type of services} will end: [insert effective date].” Effective date must be at least two days after the issue date Services must continue through the effective date
□ Font size is least 12 points. The notice will be two pages long in 12-point font. □ You have inserted in bullet #1 and bullet #2 the type of service that will be terminated
(skilled nursing, home health, hospice, or comprehensive outpatient rehabilitation).
□ Appeal rights are stated in a section titled “YOUR RIGHT TO APPEAL THIS DECISION.” □ The appeal process is outlined in a section titled “HOW TO ASK FOR AN IMMEDIATE
APPEAL.”
□ Acumentra Health’s name and correct toll-free number is inserted bullet #4 under “How to
Ask for an Immediate Appeal. The correct toll-free number is 1-800-785-0411, the only number that can be used for weekend contact. Notices without this number will be considered invalid, and a new notice will need to be issued.
□ The “OTHER INFORMATION” section includes the Medicare numbers to call for more
information about the appeals process.
□ The notice has been signed and dated by a competent beneficiary or by an authorized
representative. The date of the signature must be at least two days before the effective date coverage will end. If the beneficiary is not competent, you must follow your policy to obtain the signature from an authorized representative. You may not issue a notice to an incompetent beneficiary, even if the incompetence is temporary. If the beneficiary is not competent and the authorized representative is not available to sign, call the beneficiary’s representative and explain the appeal procedure and provide OMPRO’s toll-free phone number. Document on the notice the date and time you contacted the representative, that you explained the appeal rights, and that you provided OMPRO’s toll-free number. If these items are not documented, the notice will be considered invalid.
This material was prepared by Acumentra Health, Oregon’s Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 7SOW-OR-REV-05-02 6/7/05