Notice of Medicare Non-Coverage (NOMNC) Form

This form is for Skilled Nursing Facilities, Comprehensive Outpatient Rehabilitation Facilities, and Home Health Providers. UPMC for Life participating providers may now use the UPMC Health Plan-specific Notice of Medicare Non-Coverage (NOMNC) form required by CMS.

Members on Medicare Advantage HMO, PPO, and Special Needs Plans (HMO D-SNP) can use this form:

• UPMC for Life (Pennsylvania and Ohio) and UPMC for Life Complete Care (HMO D-SNP)