Section 1852(g)(1)(B) of the Social Security Act (SSA) requires Medicare health plans to provide enrollees with a written notice in understandable language that explains the plan's reasons for denying a request for a service or payment for a service the enrollee has already received. The written notice must also include a description of the applicable appeals processes. Regulatory authority for this notice is set forth in Subpart M of Part 422 at 42 CFR 422.568, 422.572, 417.600(b), and 417.840.
Section 1932 of the Social Security Act (SSA) sets forth requirements for Medicaid managed care plans, including beneficiary protections related to appealing a denial of coverage or payment. The Medicaid managed care appeals regulations are set forth in Subpart F of Part 438 of Title 42 of the CFR. Rules on the content of the written denial notice can be found at 42 CFR 438.404.
This notice combines the existing Notice of Denial of Medicare Coverage with the Notice of Denial of Payment and includes optional language to be used in cases where a Medicare health plan enrollee also receives full Medicaid benefits that are being managed by the Medicare health plan.
US Code:
42 USC 1395w-22
Name of Law: Implementation of Medicare Advantage Program
Statute at Large:
18 Stat. 1852
Name of Statute: null
US Code:
42 USC 1396u-2
Name of Law: Provisions Relating to Managed Care
Statute at Large:
19 Stat. 1932
Name of Statute: null
The annual hour burden associated with this collection is estimated to be 1,159,604 hours. The annual hour burden in the 2010 submission for this collection was 194,728 hours. As discussed in Supporting Statement section 12, the significant increase in the burden estimates is due to the use of Medicare health plan reported data on organization determinations which was not available when the previous PRA package was submitted for this collection. CMS believes the 2011 plan reported data are the most current and reliable data available for the purpose of developing the burden estimates for CMS-10003.
Program changes have been made since the publication of the 60-day FR notice. Those changes can be found in the NDMCP Crosswalk.
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form CMS-10003 Notice of Denial of Medical Coverage (or Payment)
Comment Chart CMS-10003_MMCO DAP_03 26 2013.docx
Notice of Denial of Medical Coverage (or Payment)