Medicare Beneficiary Notices Initiative (BNI) FFS Expedited Determination Notices
Guidance for HHAs, SNFs, Hospices, and CORFs for required Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: May 20, 2020
What's New
11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage
The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) and Detailed Explanation of Non-Coverage (DENC / CMS-10124). Please note the updated NOMNC and DENC are to be used for both Original Medicare and Medicare advantage but some of the revisions are applicable only to Medicare Advantage. (see below) Providers must use the revised NOMNC beginning January 1, 2025 for Original Medicare and Medicare Advantage. Providers must also use the revised DENC beginning January 1, 2005 for Original Medicare, but there is an extended deadline to implement the DENC for Medicare Advantage. Please see the related note below.
The updated notices, including Spanish versions, are available in the "Downloads" section below.
Some Notice Changes Only Affect Medicare Advantage
The NOMNC has been revised to reflect regulations that now afford Medicare advantage enrollees the right to appeal untimely to to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), or 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 DENC element for health plans to complete:
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.
Special Note for Medicare Advantage Only
Detailed Explanation of Non-Coverage (DENC) (CMS-10124)
This notice was released in November 2024 and was revised consistent with regulatory changes in CMS-4205-F; these regulatory changes are effective January 1, 2025. Medicare Advantage plans and Part D plan sponsors have expressed concern with implementing the revised notices close to the start of the 2025 plan year, given the need for programming and testing activities. As a result of these concerns, CMS will allow Medicare Advantage plans additional time to implement the revised DENC. MA organizations and plan sponsors must implement the DENC as soon as practicable, but no later than April 1, 2025. This extended deadline to implement the updated notice does not alter or amend the applicability date of the regulatory changes in CMS-4205-F.
This extended deadline applies only to the DENC as it is issued by a MA plan or PDP sponsors and does not apply to the updated Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) which is issued by providers. The revised NOMNC must be used beginning January 1, 2025.
General Notice Information
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
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