Form CMS-10003 NOTICE OF DENIAL OF MEDICAL COVERAGE

OMB Approval 0938-0829

NOTICE OF DENIAL OF MEDICAL COVERAGE
________________________________________________________________
Date:
Member ID Number:
Beneficiary’s name:
________________________________________________________________
We have denied coverage of the following medical services or items that you or
your physician requested:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
We denied this request because:
_________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________.
What If I Don’t Agree With This Decision?
You have the right to appeal. To exercise it, file your appeal in writing within 60
calendar days after the date of this notice. We can give you more time if you
have a good reason for missing the deadline.
Who May File An Appeal?
You or someone you name to act f
or you (your representative) may file an appeal. You can name a relative,
friend, advocate, attorney, doctor, or someone else to act for you. Others also
already may be authorized under State law to act for you.
You can call us at: (___) ________ to learn how to name your representative.
If you have a hearing or speech impairment, please call us at TTY (___) ______.
If you want someone to act for you, you and your representative must sign, date,
and send us a statement naming that person to act for you.
Form No. CMS-10003

Exp. Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0829. The time required to complete this information collection
is estimated to average 6.3 to 15minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

OMB Approval 0938-0829

IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
For more information about your appeal rights, call us or see your
Evidence of Coverage.
information that explains why we
There Are Two Kinds of Appeals
should provide the service.
You Can File
Call your doctor if you need this
Standard (30 days)- You can ask
information to help you with your
for a standard appeal. We must give
appeal. You may send in this
you a decision no later than 30 days
information or present this
after we get your appeal. (We may
information in person if you wish.
extend this time
How
Do I File An Appeal?
by up to 14 days, if you request an
extension or if we need additional
information and the extension
benefits you.)
Fast (72 hour review)- You can ask
for a fast appeal if you or your doctor
believe
that your health could be seriously
harmed by waiting too long for a
decision.
We must decide on a fast appeal no
later than 72 hours after we get your
appeal.
(We may extend this time by up to
14 days if you request an extension,
or if we need additional information
and the extension benefits you.)
• If any doctor asks for a fast appeal
for you, or supports you in asking
for one, and the doctor indicates
that waiting for 30 days could
seriously harm your health, we
will automatically give you a
fast appeal.
• If you ask for a fast appeal without
support from a doctor, we will
decide if your health requires a
fast appeal. If we do not give you
a fast appeal, we will decide your
appeal within 30 days.
What Do I Include With My
Appeal?
You should include your name,
address, Member ID number,
reasons for appealing, and any
evidence you wish to attach. You
may send in supporting medical
records, doctors' letters, or other

For a Standard Appeal: You or your
authorized representative should mail
or deliver your written appeal to the
address(es) below:

For a Fast Appeal: You or your
authorized representative should
contact us by telephone or fax:
What Happens Next? If you appeal,
we will review our decision. After we
review our decision, if any of the
services you requested are still
denied, Medicare will provide you with
a new and impartial review of your
case by a reviewer outside of your
Medicare Advantage Organization. If
you disagree with that decision, you
will have further appeal rights. You
will be notified of those appeal rights if
this happens.
Contact Information:
If you need information or help, call us
at:
Toll Free:
TTY:
Other Resources to Help You:
Medicare Rights Center:
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048