Notice of Denial of Medical Coverage (or Payment)

Form Instructions for the Notice of Denial of Medical Coverage (or Payment)
CMS-10003-NDMCP
A Medicare health plan (“plan”) must complete and issue this notice to enrollees when it
denies, in whole or in part, a request for a medical service/item or a request for payment
of a medical service/item the enrollee has already received. The notice contains text in
curly brackets “{
}” to be inserted, as applicable, as explained in these instructions.
The notice also contains text in square brackets “[
]” that is to be inserted, as
applicable, if a plan enrollee receives full benefits under a State Medical Assistance
(Medicaid) program and the plan denies a service/item that is subject to Medicaid
appeal rights. Bracketed text shown in italics must be inserted in the notice as written.
Bracketed text that is not italicized provides instruction on text to be inserted in the
notice.
The OMB control number must be displayed on the notice. The notice must be
provided in 12 point font.
Heading
• Date: Insert the month, day, and year the notice is issued.
• Name: Insert the enrollee’s full name.
• Member number: Insert the enrollee’s plan identification number. The enrollee’s
HIC number must not be used.
A plan is permitted to insert additional fields of information in the header section of the
notice consistent with applicable State requirements, such as the enrollee’s Medicaid
number, provider name, and date of service.
Section Titled: Your request was denied
The plan must insert the appropriate term to describe the action taken; that is, whether
the service was denied, stopped, reduced or, in the case of a Medicaid service,
suspended (temporarily stopping a service). If the denial involves a payment request,
the plan must insert the payment of text shown in brackets. In the free text field, the
plan must clearly and specifically list the denied medical services/items.
Section Titled: Why did we deny your request?
The plan must insert the appropriate term to describe the action taken; that is, whether
the service was denied, stopped, reduced or, in the case of a Medicaid service,
suspended (temporarily stopping a service). In the free text field, the plan must provide
a specific and detailed explanation of why the medical services/ items were denied and
must include the applicable Medicare (or Medicaid) coverage rule or applicable plan
policy (e.g., Evidence of Coverage provision) upon which the action was based.

Section Titled: You have the right to appeal our decision
The plan must insert its name in the {health plan name} field.
If the action taken involves Medicaid benefits, insert text shown in the square brackets,
as applicable (include the timeframe for requesting an appeal for a Medicaid service, if
the State timeframe is more or less than 60 days). If the enrollee is not required to
exhaust the plan level appeal before requesting a State Fair Hearing, the notice must
inform the enrollee of the right to concurrently request a plan appeal and a State Fair
Hearing. The plan must insert applicable timeframes for requesting a State Fair
Hearing.
Section Titled: If you want someone else to act for you
The plan must insert the phone and TTY numbers to be used if the enrollee needs
information on how to name a representative.
Section Titled: There are 2 kinds of appeals
Standard Appeal - As applicable, the plan must insert the adjudication timeframe for
standard Medicaid appeals.
Fast Appeal - No information to insert.
Section Titled: How to ask for an appeal with {health plan name}
In the title to this section, insert the health plan name.
Step 1: If the plan requires the appeal to be in writing, insert the bracketed option of
written. If the notice relates to a Medicaid service, insert the italicized text shown in the
square brackets.
Step 2: In the spaces provided for Standard and Fast Appeals, the plan must insert the
plan's address, phone and fax number(s). If the plan accepts standard appeal requests
by phone, insert the text shown in brackets.
Section Titled: What happens next?
If the denial involves a payment request, insert the payment of text shown in brackets.
If the notice relates to Medicaid services, insert additional State-specific rules, as
applicable.
Section Titled: How to ask for a Medicaid State Fair Hearing/What happens next?
The optional Medicaid text in brackets must be included if the plan manages both
Medicare and Medicaid benefits and the service/item is subject to Medicaid appeal
rights. If applicable, insert text shown in square brackets if a Medicaid service was
denied, stopped, reduced, or suspended. The plan must insert applicable timeframes
for State fair hearings, as well as address, phone and fax numbers. If the denied
medical services/items do not involve Medicaid services, the text related to asking for a
State Fair Hearing must not be included in the notice.

Section Titled: Get help & more information
In the spaces provided, the plan must insert the plan’s toll free phone and TTY numbers
for the enrollee, physician or representative to call if they need information or help. This
section must always be included in the notice, whether or not the notice integrates the
text from the preceding section containing bracketed language related to Medicaid State
Fair Hearings. If the notice involves a Medicaid service, the plan must insert
Medicaid/State contact information.

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.

Form Instructions CMS-10003-NDMCP

OMB Approval 0938-0829