OMB Approval 0938-0829
Form Instructions for the Notice of Denial of Medical Coverage
CMS-10003-NDMC
A Medicare Health plan (“plan”) is to complete and issue this notice when it denies an enrollee's request for medical service. This is not model language. This is a standard form. Plans may not deviate from the content of the form provided. Please note that the OMB control number and statement must be displayed on the notice.
Heading
Date.--Enter the month, day, and year that the notice is being issued to the enrollee or enrollee’s representative.
Beneficiary’s Name.--Enter the full name of the enrollee.
Member ID Number. -- Enter the enrollee’s Medical or other ID number.
We have denied coverage of the following medical services or items that you or your physician requested.--List the denied medical services or items that were requested by the enrollee or physician.
We denied this request because --The plan must provide a specific and detailed explanation why the medical services or items are being denied, with the description of any applicable Medicare coverage rule or any other applicable plan policy upon which the denial decision was based.
Section Titled: Who May File An Appeal?
In the spaces provided, the plan is required to enter the plan's telephone and TTY number(s) where the enrollee can learn how to name a representative.
Section Titled: There Are Two Kinds of Appeals You Can File
No information is required to be completed.
Section Titled: What Do I Include With My Appeal?
No information is required to be completed.
Section Titled: How Do I File An Appeal?
Under the subsection "For a Standard Appeal" -- The plan must provide the address(es) where the enrollee or representative can mail or hand deliver a standard appeal.
Under the subsection "For a Fast Appeal" -- The plan is required to enter the telephone, TTY, or fax number(s) where the enrollee or representative can request an expedited (fast) appeal.
Section Title: What Happens Next?
No information is required to be completed.
Section Titled: Contact Information
In the spaces provided, the plan is required to enter the plan’s telephone and TTY number(s) where the enrollee or representative can call if they need information or help.
Section Titled: Other Resources To Help You
No information is required to be completed.
| File Type | application/msword |
| File Title | Form Instructions for the Notice of Denial of Medical Coverage |
| Author | HCFA Software Control |
| Last Modified By | CMS |
| File Modified | 2007-01-10 |
| File Created | 2007-01-10 |