Comment Responses

CMS – 10146

Document	Page	Issue	Comment
Form	2	Column 2, under "For a Standard Appeal": the change indicates plans can only have one address, but this conflicts with the form instructions (pg 2), which say "address or addresses".	Change the form to indicate more than one address can be entered. CMS Response: The form instructions have been changed to ensure consistency with the form. The phrase “address or addresses” in the instructions has been changed to “address” to comport with the language used in the form.
Form	2	The two lines in the page heading read like an incomplete sentence.	The added sentence at the top "For more information about your appeal rights..." would be more easily understood if formatted to look different than the title line above it or placed away from the page title. CMS Response: CMS disagrees that the title reads like an incomplete sentence. However, in an effort to streamline the form, the second line has been removed from the top of the page 2; we believe it is unnecessary given that the 2nd column of page 2 contains a section entitled “Contact Information” where the enrollee is instructed to contact the plan if information or help is needed; the Part D plan is required to enter the plan’s telephone and TTY numbers in this section.
Form	2	Under first column, Expedited, second bullet. Currently the following sentence is not stated clearly: “If we do not give you an expedited appeal, we will decide your appeal within 7 days.”	Recommend the following language instead: “We will notify you if we do not give you an expedited appeal and we will decide your appeal within 7 days.” CMS Response: The suggested change has been incorporated into the form.
Form Instructions	1	Under Heading section, “Member’s Name” doesn’t match field name in the form.	Change instructions to read “Member Number”. CMS Response: The suggested change has been incorporated into the form; “Member’s Number” has been changed to “Member number” to comport with the form.
Form Instructions	1	Under Heading section, it states “The plan’s explanation must be written in a manner calculated to be understood by the enrollee.”	Recommend aligning this with the §423.568(d) language which reads “must use approved language in a readable and understandable form” CMS Response: No changes have been made to the form instructions as a result of this comment. The regulatory language the commenter cites refers to the approved notice language of the standardized form; conversely, the form instructions refer to the denial explanation provided by the Part D plan in the free-text field of the form.