Form CMS-10003 NDMC CMS-10003 NDMC Notice of Denial of Medical Coverage

OMB Approval 0938-0829

NOTICE OF DENIAL OF MEDICAL COVERAGE

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Date: Member ID Number:

Beneficiary’s name:

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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 for 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 8/31/2010

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

IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS

For more information about your appeal rights, call us or see your Evidence of Coverage.

There Are Two Kinds of Appeals

You Can File

Standard (30 days)- You can ask for a standard appeal. We must give you a decision no later than 30 days 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.)

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.)

1. • 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.

2. • 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 information that explains why we should provide 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.

How Do I File An Appeal?

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 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