NDMC - 2010 - 508--07-21-10-Track Changes

Notice of Denial of Medical Coverage

Date: Member number:

Beneficiary’s name:

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. 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 your treating physician may file an appeal. Or you may name a relative, friend, advocate, attorney, doctor (other than your treating physician), or someone else to act as your representative. 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 CMS-10003-NDMC (Exp. xx/2013) 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 up to 30 days 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.) 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. If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. We will notify you iIf we do not give you a fast appeal, and we will decide your appeal within 30 days. What do I include with my appeal? Your written request should include: your name, address, member 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.

How Do I File An Appeal? For a Standard Appeal: Mail or deliver your written appeal to the address below: For a Fast Appeal: 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

Form CMS-10003-NDMC (Exp. xx/2013) OMB Approval 0938-0829