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New NOMNC and DENC Notices Effective January 1

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). These renewed notices contain updates which are applicable only to Medicare Advantage enrollees. The new notices must be used beginning January 1, 2025.

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, 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.

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Hospices, and Outpatient Rehab Facilities are required to provide a NOMNC to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries on how to request an expedited determination from their BFCC-QIO and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO. A DENC is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered services.

Full instructions for the Original Medicare (also known as Fee for Service or FFS), expedited determination process are available in Section 260, of Chapter 30 of the Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual. 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.

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