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September 25, 2013
IMPORTANT INFORMATION REGARDING THE NOTICE OF
MEDICARE NON-COVERAGE (NOMNC) FORM
In May, 2013 CMS prepared a notification that the Notice of Medicare Non-Coverage (NOMNC) form
must include the Medicare patient number. In the past the Health Plan’s member number was used in
this space. That is no longer acceptable practice with CMS. As our healthcare partners we seek to ensure
compliance with CMS regulations when servicing our members. To that end, please make any necessary
changes to ensure delivered NOMNC’s have the Medicare patient number on page #1 of the form.
See notice:
MLN Matters® Number: MM7903 Revised
Related Change Request (CR) #: CR 7903
Related CR Release Date: May 24, 2013
Effective Date: August 26, 2013
Related CR Transmittal #: R2711CP
Implementation Date: August 26, 2013
260.3.2 - Completing the NOMNC
(Rev.2711, Issued: 05-24-13, Effective: 08-26-13, Implementation: 08-26-13)
Providers must use the OMB-approved NOMNC (CMS-10123). Providers must type or write the
following information in the corresponding blanks of the NOMNC:
 Patient name
 Medicare patient number
 Type of coverage (SNF, Home Health, CORF, or Hospice)
 Effective date (last day of coverage)
Note: The effective date is always the last day beneficiaries will receive coverage for their services.
Beneficiaries have no liability for services received on this date, but may face charges for services
received the day following the effective date of the NOMNC for home health, hospice, and CORF
services. Because SNFs cannot bill the beneficiary for services furnished on the day of (but before the
actual moment of) discharge, beneficiaries may leave a SNF the day after the effective date and not face
liability for such services.
CMS has published the NOMNC form at the following internet site: http://cms.gov/Medicare/MedicareGeneral-Information/BNI/FFSEDNotices.html
The NOMNC forms may also be found on our websites at www.healthplanofnevada.com or
www.sierrahealthandlife.com, Click on Providers, then Online Provider Information.
If you have any questions regarding this facsimile please contact Provider Services at (702) 242-7088 or
(800) 745-7065, Monday – Friday from 8:00 AM to 5:00 PM PST.