Crosswalk- Denial Notice 2013(v2)

Crosswalk for Changes to Notice of Denial of Medicare Prescription Drug Coverage
(CMS-10146)

Summary of Changes to CMS-10146

1. General Changes: We have added clarification to the notice, including adding language that is similar to other Medicare denial notices, in order to make the notice easier for Part D Plans to use, and for Part D enrollees to understand.

2. Denials for drugs that are not covered under Part D: We have also added optional language into the denial rationale box for plans that issue a specific type of denial- specifically when a plan denies a drug under Part D because the drug may be covered under a different benefit such as Part B. We believe adding this optional language will ensure denial notices are easily understood by the enrollees, but will also ensure enrollees have prompt access to their medications. We also believe that creating pre-populated optional language will be less burdensome for plans that are currently populating their own language for these denials.

Section on Current CMS-10146	Type of Change	Rationale for Change
General Information	Added Header to explain in plain language that enrollees can appeal this denial	Draws attention to appeal rights from the beginning of the notice in order to ensure enrollees’ understanding of rights and instructs enrollees where to go for more information (“Get help and more information” section)
Your Request was denied	Clarified language “claims were denied under Medicare Part D”	Meant to clarify to enrollees that drugs denied are being denied under the Part D benefit and not necessarily by all Medicare benefits (for instance Part B)
Why did we deny your request	Modified first sentence to reflect regulatory language	We changed this language to ensure plans are adding specific rationale as required by regulations and Chapter 18 guidance. It now reflects the language that is currently in the regulatory and manual guidance.
Why did we deny your request	Included optional language for Part D denials where the drug may be paid for by a different benefit.	Part D plans (especially MAPD) have inquired about how to issue a denial letter when a drug is being denied under Part D but is being covered under a different benefit. Since this can be confusing to the beneficiary, and burdensome to the plan, we created optional language that can be used to explain what a beneficiary should do if a drug is being denied under Part D but is possibly covered under a different benefit.
Contact Information	Deleted	We added a new section called “Get help and more information” to replace the section called “contact information”.
Get Help and More Information	Added this section for plan numbers, website and hours of operation	This change was to make the section more understandable to beneficiaries that the contact numbers listed were for the purpose of helping the beneficiary appeal. The change also makes the language in this notice consistent with other Medicare denial notices.

Summary of Changes to Instructions:

The following changes have been made to the instructions as a result of changes made to the denial notice, and for the purpose of enhancing the clarity or accuracy of the instructions:

• Text has been added to the introductory paragraph to provide an explanation that text shown in brackets are instructions in the notice for what a plan should do, while text in the brackets that are italicized must be entered as written (when applicable).

• Made formatting changes to bold the heading titles.

• Created a heading for the “Your request was denied” in order to enhance clarity for Part D plans.

• In the “Your request was denied” section, deleted the non-instructional language and kept only the actual instructions for the plan.

• Added a header for the “why did we deny your request” section.

• In the “Why did we deny your request” section, made language changes that were not substantive in the first paragraph in order to mirror the regulatory language.

• Added new language under the first paragraph to explain the new bracketed language in the denial notice, specifically:

  • Created a new section for B versus D denials and denials for drugs not covered under Part D.

  • Added language in the new section in order to explain to plans that the new bracketed language will only apply for a specific type of denial- B v. D or drugs not covered under part D.

  • Added new instructions for how a plan should insert the bracketed language in the notice in order to explain denial notice changes.

  • Created two examples for plans to refer to that show how the new language in the denial notice should be used.

• Deleted the “contact information” instructions which have also been deleted in the notice.

• Created a “Get help and more information” section to mirror the denial notice.

• Added instructions into the “Get help and more information” that instructs plans to also include their hours of operation and plan website.