Cms-10003 Ndp Notice Of Denial Of Payment

OMB Approval 0938-0829

NOTICE OF DENIAL OF PAYMENT

Date:

Member ID Number:

Beneficiary’s name:

We,________________________________________________________________________,
recently received a claim for: _____________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
provided to you by __________________________________________on ________________.
____________________________________________________________________________
We will not pay for _____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________.
because:_____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

CMS Form 10003-NDP

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.
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 for you
(your authorized 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 authorized representative.
[If you have a hearing or speech impairment,
please call us at TTY/TTD
(___)__________].
If you want someone to act for you, you and
your authorized representative must sign,
date and send us a statement naming that
person to act for you.
How Do I File An Appeal?
You or your authorized representative
should mail or deliver your written appeal
to the address(es) below:

We must give you a decision no later than
60 calendar days after we receive your
appeal.
Form No. CMS-10003

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 information
that explains why we should pay for the
service. Call your doctor if you need this
information to help you with your appeal.
You may send in this information or present
this information in person if you wish.
What Happens Next?
If you appeal, we will review our decision.
After we review our decision, if payment for
any of your claims is still denied, Medicare
will provide you with a new and impartial
review of your case by a reviewer outside of
your Medicare Health Plan. 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
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 15 minutes 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