Crosswalk -- Changes to NDP-NDMC - 2010-FINAL

Crosswalk Document for Changes to CMS-10003

Notice of Denial of Payment / Notice of Denial of Medical Coverage

Submitted for Collection March 2010

Summary of Changes to CMS-10003:

Medicare health plans are required to issue the Notice of Denial of Medical Coverage (NDMC) and the Notice of Denial of Payment (NDP) when a request for either a medical service or payment is denied in whole or in part. These notices inform beneficiaries of the reasons their request was denied and of their right to file an appeal. Medicare health plans, including Medicare Advantage plans, cost plans, and Health Care Prepayment Plans (HCPPs), are required to use these standardized notices. (42 CFR 422.568 and Chapter 13 of the Medicare Managed Care Manual.)

This package incorporates minor formatting changes to the form and the instructions to comply with section 508 accessibility requirements, to improve clarity and readability and to achieve consistency with other related notices. Additionally, we have made other, material changes to the packages to comply with new regulations and to clarify existing requirements. These changes to the notices are not expected to affect the amount of time required to prepare an individual notice.

Non-substantive changes to NDP/NDMC and instructions :

• Changes in line spacing and formatting to improve readability.

• Revisions for Section 508 non-compliance

• Revisions for clarity and consistency with existing CMS guidance.

• To minimize the length of this form, we moved the PRA disclosure language from the notices to the form instructions. Accordingly, we also removed language from the instructions requiring the PRA disclosure statement to be displayed on the form.

Substantive changes to NDP/NDMC and instructions:

• To be consistent with recent regulatory changes, under “Who May File An Appeal” in the NDMC, we added language clarifying that an enrollee’s “treating physician” may request a standard reconsideration on behalf of an enrollee. The NDMC was revised to reflect this regulatory change so that the notice accurately informs Part C enrollees of the appeals process.

• As stated in 42 CFR 422.568(c), CMS added “in whole or in part” to the description of the circumstance under which written notice is provided. This change was intended to clarify that a plan is required to complete and issue written notice when it partially or wholly denies a request for medical service – i.e., notice is required for partial payments or partial coverage of a requested service.