Crosswalk Coverage Denial Notice 04 2008

Crosswalk Document for Changes to CMS-10146

Notice of Denial of Medicare Prescription Drug Coverage

Submitted for Collection May 2008

Summary of Changes to CMS-10146:

The form “Notice of Denial of Medicare Prescription Drug Coverage” is used by Part D plans to notify an enrollee when the plan denies coverage for a prescription drug. Based on experience since inception of the Part D program in January 2006, CMS believes that this standardized notice should be revised to include certain nonsubstantive changes for purposes of providing a clearer denial notice to Part D program enrollees. These changes do not affect the burden associated with the denial notice.

The following nonsubstantive changes have been made to the form:

• In each instance where “physician” or “doctor” was used, the form now uses “prescriber” to account for instances where an enrollee’s prescription is written by a non-physician provider with prescribing authority under State law, such as a nurse practitioner or physician’s assistant.

• Under the section entitled “What If I Don’t Agree With This Decision?” we’ve added language to clarify that an enrollee has the right to ask for an exception to a coverage rule, such as prior authorization or a quantity limit.

• Under the section entitled “Who May Request an Appeal?” we’ve eliminated the use of the term “appointed representative” and have used the more concise term “representative.” We’ve clarified that a standard appeal can be requested by the enrollee or his or her representative.

• On page 2, under the section “There are Two Kinds of Appeals You Can Request/Expedited (72 hours)” we’ve clarified that the enrollee, the enrollee’s prescriber or the enrollee’s representative can request an expedited appeal. As previously noted, we’ve used “prescriber” instead of “doctor.” Under the subsection “Standard (7 days)” we’ve clarified that the enrollee and the enrollee’s representative can request a standard appeal.

• Under “How Do I Request an Appeal” we’ve changed “doctor” to “prescriber” and “appointed representative” to the more concise term “representative.”

The following changes have been made to the instructions:

• In the instructions for “Heading/Date” we’ve changed the term “appointed representative” to the more concise term “representative.”

• In the instructions for “Who May Request an Appeal” we’ve changed the term “appointed representative” to the more concise term “representative.”

• Instructions for “How Do I Request an Appeal” subsection “For an Expedited Appeal” now include a reference to the enrollee’s prescriber for purposes of consistency with page 2 of the denial notice that explains that the enrollee, the enrollee’s prescriber or the enrollee’s representative may contact the plan at the numbers provided to request an expedited appeal. We’ve changed the term “appointed representative” to the more concise term “representative” throughout this section.

• For the section titled “Contact Information” we’ve changed “appointed representative” to the more concise term “representative.”