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Notice
of Denial of Payment
Date:
Member number:
Beneficiary’s
name:
We, ,
recently received a claim for:
provided to you by
on .
We will not pay for:
.
Because
.
Form CMS 10003-NDP (Exp.
XX/2013) OMB Approval 0938-0829
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 may file an appeal. If you don’t
want to file an appeal yourself, you may name a relative, friend,
advocate, attorney, doctor, 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. 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.
How Do I File An Appeal?
Mail or deliver your written appeal to
the address below:
We must give you a decision no later
than 60 calendar days after we receive your appeal request.
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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 supporting medical records,
doctors’ letters, or other information that explains why we
should pay for the service. Call
your doctor if you need this information to help you with your
appeal. You may send this information or present this information
in person if you wish.
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 number 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
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Form CMS 10003-NDP (Exp.
XX/2013) OMB Approval 0938-0829
| File Type | application/msword |
| File Title | NOTICE OF DENIAL OF PAYMENT |
| Subject | Notice of Denial of Payment |
| File Modified | 2010-07-21 |
| File Created | 2010-07-21 |