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)