{Insert logo here} NOTICE OF MEDICARE PROVIDER NON-COVERAGE Patient Name: Medicare Number: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type} Your provider has 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 {insert type} services you receive after the above date. YOUR RIGHT TO APPEAL THIS DECISION You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services. Call your QIO at: {insert name and number of QIO} to appeal, or if you have questions. See the back of this notice for more information. OTHER INFORMATION: Contact 1-800-MEDICARE (1-800-633-4227), or TTY/TDD: 1-877-486-2048 for more information about the appeals process. ADDITIONAL INFORMATION (OPTIONAL) Please sign below to indicate that you have received this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. __________________________________________ _____________ Signature of Patient or Authorized Representative Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0xxx-xxxx. The time required to prepare and distribute this collection is 5 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
OMB Approval No. xxxx-xxxx
SERVICES WILL END: {insert effective date}
If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer will also 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.
HOW TO ASK FOR AN IMMEDIATE APPEAL
Form No. CMS-10123 Exp. Date xx/xx/xxxx