NDMCforminstructionstrackchanges508

OMB Approval 0938-0829

Form Instructions for the Notice of Denial of Medical Coverage

CMS-10003-NDMC

A Medicare health plan (“plan”) is to complete and issue this notice when it denies a request for medical service, in whole or in part. This is not model language. This is a standard form. Plans may not deviate from the content of the form provided. Please note that the OMB control number must be displayed on the notice.

Heading

• Date.--: Enter the month, day, and year that the notice is being issued.

• Beneficiary’s Name.--name: Enter the full name of the enrollee.

• Member Number.--number: Enter the enrollee’s Mmedical or other IDidentification number. (HIC nNumber may must not be used..)

• We have denied coverage of the following medical services or items requested.--: List the denied medical services or items.

• We denied this request because.--: The plan must provide a specific and detailed explanation of why the medical services or items are being denied, with the description of any applicable Medicare coverage rule or any other applicable plan policy upon which the denial decision was based.

Section Titled: What If I Don't Agree With This Decision?

No information is required to be completed.

Section Titled: Who May File An Appeal?

In the spaces provided, the plan is required to enter the plan's telephone and TTY number(s)numbers where the enrollee can learn how to name a representative.

Section Titled: There Are Two Kinds of Appeals You Can File

No information is required to be completed.

Section Titled: What Do I Include With My Appeal?

No information is required to be completed.

Section Titled: How Do I File An Appeal?

Under the subsection "For a Standard Appeal" -- The”, the plan must provide the address where the enrollee, physician or representative can mail or hand deliver a standard appeal.

Under the subsection "For a Fast Appeal", -- Tthe plan is required to enter the telephone, TTY, or fax number(s)numbers where the enrollee, physician or representative can request an expedited (fast) appeal.

Section Titled: What Happens Next?

No information is required to be completed.

Section Titled: Contact Information

In the spaces provided, the plan is required to enter the plan’s telephone and TTY number(s)numbers for the enrollee, physician or representative to call if they need information or help.

Section Titled: Other Resources to Help You

No information is required to be completed.[PLACEHOLDER FOR NEW DISCLOSURE STATEMENT + NOTICE EXPIRATION DATE].

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 10 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 or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attention: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.