CMS-10124-DENC · CMS
Provides detailed explanation of why Medicare will no longer cover services. Issued alongside the NOMNC when beneficiary requests an expedited review.
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Delivered to you by your Medicare Advantage plan or provider
You receive this notice when your MA plan is terminating coverage for a service.
Filing Deadline
You must request a fast appeal by contacting your MA plan by the date shown on the notice (typically within 1 day of receiving it).
Your MA plan must make a decision as fast as your health requires but no later than 72 hours. If you request QIO review, the QIO decides within 2 days.
Your MA plan or the QIO will review whether continued coverage is appropriate. You are not financially liable for continued services while the appeal is pending.
CMS-40B · CMS
Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.
CMS-L564 · CMS
Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.
CMS-10797 · CMS
Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.
CMS-10798 · CMS
Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.
Plan-specific (CMS model template) · CMS
Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.
CMS model disenrollment form · CMS
Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.
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