Hello Chris,
This link will provide you guidance on a Notice of Medicare Non-Coverage (NOMNC): https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices512
The downloads section of this page will have links for the form and instructions. Currently, the form is not available electronically within the Axxess solution. Typically, a provider will have a NOMNC produced on multi-part paper (white copy/yellow copy) to reflect their contact information and have a record of the document.
Thanks,
Sal