Crosswalk - DENC Instructions

2011 (old version)	2014 (new version)	Type of Change	Reason for Change	Burden Change
A Medicare provider/health plan (“plan”) must provide a completed copy of this notice to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility , and hospice services upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed the termination of services in these settings. This notice fulfills the requirements at 42 CFR 405.1202(f)(1) and 42 CFR 422.626(e)(1), and must be provided no later than close of business of the day of the QIO’s notification.	A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as “plans”) must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed the termination of services in these settings. The DENC must be provided no later than close of business of the day of the QIO’s notification.	Rev	Improve precison and clarity of instructions.	No
Do not use the DENC if coverage is being terminated for any of the following reasons: • Because the Medicare benefit is exhausted; • For denial of Medicare admission to a skilled nursing facility or comprehensive outpatient rehabilitation facility or denial of Medicare home health services; • For denial of a service that is not a Medicare benefit; or • Due to a reduction or termination of a Medicare-covered service that does not conclude the skilled Medicare stay. In these cases, the plan must issue the CMS form 10003 – Notice of Denial of Medical Coverage (NDMC). The DENC is a standardized notice. Providers/plans may not deviate from the wording or content of the form except where authorized to do so. Please note that the OMB control number must be displayed in the upper right of the notice. Notice entries may be typed or handwritten. Handwritten entries must be at least as large as 12-point type and legible.	Removed	Rev	Improve precison and clarity of instructions.	No
New Language for 2014	Alterations to the DENC Providers may include their business logo and contact information on the top of the DENC. Text may not be moved to a second page to accommodate large logos, address headers, etc.	Rev	Improve precison and clarity of instructions.	No
The name, address and telephone number of the provider or plan that actually delivers the notice must appear above the title of the form.	The name, address and telephone number of the provider or plan that delivers the notice must appear above the title of the form.	Rev	Improve precison and clarity of instructions.	No
Date: Fill in the date the notice is generated by the plan.	Date: Fill in the date the notice is generated by the provider or plan.	Rev	Improve precison and clarity of instructions.	No
Patient Name: Fill in the beneficiary/enrollee first and last name.	Patient Name: Fill in the beneficiary’s/enrollee’s first and last name.	Rev	Improve precison and clarity of instructions.	No
Member number: Fill in the beneficiary/enrollee medical record or identification number. Note that the HIC number must not be used.	Member number: Fill in the beneficiary’s/enrollee’s medical record or identification number. The beneficiary’s/enrollee’s HIC number must not be used.	Rev	Improve precison and clarity of instructions.	No
The detailed explanation of why your services are no longer covered under your plan:	The detailed explanation of why the services are no longer covered.	Rev	Improve precison and clarity of instructions.	No
The plan policy, provision, or rationale used in the decision if the notice is delivered to a heatlh plan enrollee: Fill in the reasons services are either no longer reasonable or necessary for the enrollee or are no longer covered according to the plan’s policy guidelines. Describe how the enrollee does not meet these guidelines. If the plan relied exclusively on Medicare coverage guidelines, please indicate so here.	(Plans only) The plan policy, provision, or rationale used in the decision if the notice is delivered to a health plan enrollee: Fill in the reasons services are no longer covered according to the plan’s policy guidelines, if applicable. Describe how the enrollee does not meet these guidelines. If the plan relied exclusively on Medicare coverage guidelines, please explain that here.	Rev	Improve precison and clarity of instructions.	No
The provider/plan should provide a telephone number for beneficiaries/enrollees to get a copy of the relevant documents sent to the QIO.	Provide a telephone number for beneficiaries/enrollees to get a copy of the relevant documents sent to the QIO.	Rev	Improve precison and clarity of instructions.	No