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 when the language applies
under state Medicaid rules. 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.
When the Spanish-language version of this notice is used, the Medicare health plan
must make insertions on the notice in Spanish. Additional steps need to be taken to
ensure that the enrollee comprehends the content of the notice.
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,
including a description of the applicable Medicare (or Medicaid) coverage rule or
applicable plan policy (e.g., Evidence of Coverage provision) upon which the action was
based. A specific explanation about what information is needed to approve coverage
must be included.

Plans that provide both Medicare and Medicaid benefits (e.g., integrated Dual Special
Needs Plans) should determine if the request for payment or coverage concerns a
service or item covered under the plan’s Medicare or Medicaid benefits. Plans can make
such determinations based on consideration of the following criteria:
•
•
•

The item or service is identified in plan materials, such as the Evidence of
Coverage (Enrollee Handbook), as solely a Medicaid benefit;
The item or service was previously approved solely under the plan’s Medicaid
benefits, and the request is for reauthorization or payment for services following
such approval (see below for more discussion);
The service is only covered under the plan’s Medicaid benefits and never covered
by Medicare and not covered by the MA plan as a supplemental Medicare benefit
(Medicaid-only services are generally limited to non-medical services such as
Medicaid home- and community-based long term services and supports that the
plan is contracted to provide to eligible Medicaid beneficiaries, such as personal
care attendants. Integrated plans should work with their states to develop a
definitive list of these Medicaid-only services.).

If the request is classified by the plan as a request for payment or coverage under the
plan’s Medicaid benefits that is fully covered under the plan’s Medicaid benefits the IDN
should not be sent. If the request is classified as a request for only Medicaid coverage,
and the plan denies coverage or payment in whole or in part under the plan’s Medicaid
benefits, then the plan should send any notices required to meet state Medicaid notice
requirements.
When an integrated D-SNP receives a request for payment or coverage that cannot be
readily classified falling solely under the plan’s Medicaid benefits (e.g., the request is for a
service with overlapping Medicare and Medicaid coverage, such as home health services,
or the request is not specific enough to classify, such as a request for a home health
aide), and the plan determines the item or service is not covered under the plan’s
Medicare benefits, but is fully covered under the plan’s Medicaid benefits, then the plan
must send a notice informing the plan enrollee of the denial of Medicare coverage and the
relevant Medicare appeal rights. Further, in situations where there is any chance of
Medicare coverage, but the plan provides coverage only under the Medicaid benefit, the
plan must send a notice informing the plan enrollee of the denial of Medicare coverage
and the relevant Medicare appeal rights. The plan must use the IDN to fulfill this
requirement and use the free text field to explain that the service/item will be covered
under the enrollee’s Medicaid benefits (in addition to the required explanation related to
the Medicare denial). For example, the free text field could include the following:
“Medicare doesn’t cover (insert medical service) because (insert detailed rationale).
However, since we manage both your Medicare and Medicaid health benefits, we have
determined that the service can be covered under your Medicaid benefits and we have
authorized coverage for you to receive (insert medical service).”
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 a plan-level 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 with {health plan name}
Standard Appeal - As applicable, the plan must insert the adjudication timeframe for
standard Medicaid appeals.
Fast Appeal - No information to insert. For notice of payment denials, plans may delete
this section.

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. For notice of payment denials, plans may
delete the “Fast Appeal” section.

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. If applicable, the plan should insert state/local
disability and aging services 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