Medicare health plans, including
Medicare Advantage plans, cost plans, and Health Care Prepayment
Plans (HCPPs), are required to issue written notice of denials of
payment or services, in whole or in part, to their enrollees. The
denial notice must include a statement in understandable language
of the reasons for the denial and a description of the applicable
reconsideration and appeals processes. The NDP and NDMC were
developed to comply with the Section 1852(g)(1)(B) of the Social
Security Act. Regulatory authority for the NDMC and NDP are found
at 42 CFR 422.568, and 42 CFR 417.600(b). Also, 42 CFR 417.840
applies certain Subpart M notice and appeal rules to cost plans and
HCPPs. Additionally, CMS recently published a final rule with
comment, "Medicare Program; Medicare Advantage and Prescription
Drug Benefit Programs: Negotiated Pricing and Remaining Revisions,"
which added language to 42 CFR 422.578 and 42 CFR 422.582. This
rule permits a physician providing treatment to an enrollee, upon
providing notice to the enrollee, to request a standard
reconsideration of a pre-service request for reconsideration on the
enrollee's behalf.
US Code:
42
USC 1395w-22 Name of Law: Implementation of Medicare Advantage
Program
Statute at Large: 18
Stat. 1852 Name of Statute: null
The increase in burden is due
to the rise in the number of Medicare health plans and enrollees.
Since 2005, the number of plans has increased from 454 to 740, and
the number of enrollees has risen from 7.3 million to 10.9 million.
Additionally, we adjusted our methodology for estimating the total
number of denial notices. Also, there was a substantive change to
the form and instructions. For additional information, refer to the
crosswalk document.
$0
No
No
No
No
No
Uncollected
Bonnie Harkless
4107865666
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Crosswalk -- Changes to NDP-NDMC - 2010-FINAL.docx
NDP - 2010 - 508--07-21-10-Track Changes.doc
Notice of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)