Response to Public Comments

Comments Received on Integrated Denial Notice (CMS–10003) – 60 day comment period
Document
(specify
notice,
instructions,
burden
estimates)
Instructions

Page
#

1

Comment (commenter and summary of comment)

PrimeWest Health, Rebecca Fuller
Why Did we deny your request (instructions):
PrimeWest Health respectfully does not agree with the
instructions to send a denial notice when Medicare
doesn’t cover something but Medicaid would. Sending
this denial notice when a service is, in fact, going to be
covered under the Medicaid benefit would be
confusing to members and cause unnecessary worry for
them. Members should not have to worry whether
Medicaid or Medicare is covering their services. That is
actually the point of a dual-eligible plan. Also, such a
change would add additional administrative burdens
for plans.

Notice,
Instructions

SNP Alliance, Pamela Parker
Questions Related to the State Medicaid Agency Appeal
Rights and Notices
1. When the plan determines that the item or service is
to be denied under both Medicare and Medicaid, plans
are instructed to include the appropriate Medicaid
appeal rights and instructions on how a member may
ask for a Medicaid State Fair Hearing. When the plan
issues the IDN in this scenario, it is assumed that the
plan would not issue a Medicaid Notice of Action (NOA)
and Medicaid State Fair Hearing form to the member,
in addition to the IDN. For the denial scenario noted
above, is there an assumption by CMS that plans should
obtain an approval from each of their State Medicaid
partners for issuing the IDN to the member in lieu of

CMS Response

1. CMS acknowledges the
changes in the instructions
regarding when CMS-10003
should be issued has the
potential to cause member
confusion and increase
additional administrative
burden to plans. Therefore,
we have made revisions to
the instructions. The
instructions now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.
1. The comments related to
obtaining approval from
each state for issuing the
IDN in lieu of the state’s
required notices is outside
the scope of this PRA
package.
2. Again, the comments
related to each state’s
required notices and how to
use with the IDN is outside
the scope of this PRA
package.
3. Because this comment is
related to coordination
between CMS and state
Medicaid agencies, it is also
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the state’s required NOA and Medicaid State Fair
Hearing forms?
2. If the State Medicaid agency does not approve the
plan’s use of the IDN in lieu of issuing the NOA and
State Fair Hearing Form, the plan would not include the
Medicaid appeal rights and/or instructions for
requesting a State Fair Hearing as part of IDN verbiage.
Will the plan be cited by CMS for noncompliance by not
adhering to the CMS IDN Form Instructions?
3. If the State Medicaid agency approves the use of the
IDN to include the Medicaid appeal rights, butrequires
the plan to include the State Fair Hearing form with the
IDN, the IDN notice and form may result in a document
that could potentially be 6 (six) or more pages long.
With the knowledge that a disproportionate share of
the dually eligible member population are frail, have
significant cognitive impairments, or disabilities such as
mental illness or intellectual and development
disabilities, receiving this lengthy notice from their plan
may be intimidating and confusing, which may result in
the member not reading the notice at all. This poses a
concern since plans are aware of the importance of
their members understanding this important
communication regarding denial of requested medical
services.
We request that CMS coordinate with Medicaid at CMS
and state levels to provide answers to these questions
and to develop coordinated Medicare Medicaid policy
that simplifies and streamlines these materials to
reduce the burden on beneficiaries.

outside of the scope of this
PRA package.
4. CMS acknowledges the
changes in the instructions
regarding when CMS-10003
should be issued has the
potential to increase
member confusion, result in
duplicative notices, increase
administrative burden for
plans, and increase the
number of appeals.
Therefore, we have made
appropriate revisions the
instructions. The
instructions now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.

4. Dramatic Expansion of Scope of Use in Issuance of
Medicare Denials for All Covered Medicaid Services
We are very concerned about new language that
appears in the instructions under the section titled
“Why Did We Deny Your Request?” which appears to
greatly expand the scope of use of this document and
require its issuance whenever a Medicaid service is
covered in an integrated plan. This instruction could
result in millions of new duplicative and confusing
notices to beneficiaries. We understand that under this
instruction, the IDN notice would continue to be sent
for any Medicare covered service that is denied, and
that the language would allow for explanation when
that service can be provided under Medicaid. In these
situations, there is overlap between the same Medicare
2

and Medicaid services where Medicaid may have
different coverage criteria and thus can provide
essentially the same service under Medicaid coverage
criteria. Used in this manner, this notice continues to
serve an appropriate and important function and we
support its continued use. However, if our
understanding is correct, we are very concerned that
these instructions go much further and represent a
large policy change for integrated programs, greatly
expanding the scope and use of this notice and
dramatically increasing the administrative burden on
enrollees as well as plans and states involved in offering
these products. Taken literally, and based on
information from parties who have had discussions
with CMS on this topic, the notice instructions appear
to assume that all requests for service to the integrated
plan are treated as if they are requests for Medicare
services, even if those services are exclusively
Medicaid-covered services and would never be covered
by Medicare.
Currently, integrated plans would not send a Medicare
denial notice for service requests covered only under
their state Medicaid contract and use of this notice in
this manner ignores the fact that a plan has a separate
contract with the state to provide a different set of
services under Medicaid.
The proposed change does not support current personcenteredness integration efforts already underway.
Beneficiaries receiving a notice entitled Notice of Denial
of Medical Coverage are likely to be confused and/or
upset by the title alone. Use of such a notice is helpful
when an actual Medicare service is being denied,
because it can assure the member that services will still
be covered under Medicaid. But expanding the use of
such a notice to Medicaid services not covered by
Medicare will be unnecessarily confusing to members.
Members may be even more confused about why they
are getting a Medicare Denial notice for Medicaid only
services actually being provided by the plan, thus
resulting in a significant amount of unnecessary calls to
Medicare, State Agencies and providers.
If these instructions are to be taken literally, it will
mean a huge increase in the number of denials sent to
beneficiaries by integrated plans because Medicaidonly covered services are often high frequency services
such as personal care, transportation and interpreter
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services resulting in millions and millions of additional
notices. States already have their own requirements
for notices that must be sent when Medicaid services
are approved or denied so these additional Medicare
notices indicating that services provided under
Medicaid are covered will be duplicative.
All of these additional notices could then generate
additional Medicare appeals from members who are
confused because they are receiving a denial from
Medicare and think that that something has gone
wrong and that Medicare should have covered the
Medicaid service. This could result in other potential
inadvertent consequences for plans such as increased
appeals volumes and impacts on Star Ratings.
SNP Alliance member plans and states with which they
contract who are aware of this issue say that if the
interpretation that they have discussed with CMS
prevails, complying with this new instruction will also
require significant changes in state contracts with
integrated plans and state policy as well as systems
programming for generation of notices. Some states
and plans already have mechanisms in place to
coordinate their current Medicaid notice requirements
along with current Medicare requirements using state
and plan electronic systems to collect information on
both sets of services. The change in requirements
under this document would require programming
changes in those systems.
We believe the burden time and cost estimates
provided by CMS for this provision for plans, states and
beneficiaries are vastly underrepresented in the
supporting documentation because this requirement is
likely to generate significant additional administrative
paper work, systems costs and millions of new denial
notices most of which will be duplicative (e.g., a
Medicare denial and a Medicaid approval – for the
same service). We are further concerned that such a
large policy change is being implemented through a
CMS notice process related to the Paperwork
Reduction Act, which is not where many stakeholders
would expect to find a change of this magnitude.
We strongly request that CMS clarify these instructions
to apply only where there is a clearly overlapping
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Notice

Page
s 1, 3

service between Medicare and Medicaid, and to
exclude services that are covered only by Medicaid.
Emblem Health, Lauren Parrish
1. Appeal section:
Consider adding "calendar" to the timeframe of 60
days..."60 calendar days"; this would help to provide
clarification to the Medicare members that they have
60 calendar days from the IDN letter date to initiate an
appeal.
2. Step 2 for a Standard Appeal section:
Consider addition instructions recommending health
plans to include a "delivery in-person address" when
the "mail to address" is a P.O. Box; the "delivery inperson address" option would ensure Medicare
members' standard appeals are received in a timely
manner (versus sending the appeal mail envelope to a
P.O. Box).
3. Why did we deny your request Section:
under specific rationale, add (in easily understandable
language)

Notice,
Instructions

4. Page 3 - Step 2: add TTY.
Anthem, Inc., Leah Hirsch
1. You have the right to appeal our decision section:
CMS has inserted the following language:
“State Fair Hearing: Ask for a State Fair Hearing within (
) days of the date of this notice. You have up to ( ) days
if you have a good reason for being late. See page
(insert page number) of this notice for information
about how to ask for a State Fair Hearing.”
Given that the generation of notices is an automated
process for most plans and the notices generated for
each member may vary in length based on the number
of procedure codes/descriptions for each claim, the
system has no way of tracking/determining in each case
which page of the denial notice for each member has
the information pertaining to the State Fair Hearing, As
a result, complying with this requirement will be very
problematic for plans.
We recommend that quoted text in comment section
be replaced by the following language, since
information regarding the State Fair Hearing may

1. CMS has determined the
current language is
appropriate.
2. Per commenter’s
suggestion, we have added
a section for “In-person
delivery address” in curly
brackets to be used, if
applicable.
3. CMS has added additional
language in “Section Titled:
Why did we deny your
request?” to clarify what
must be included in denial
rationale.
4. CMS accepted the comment
to add TTY to applicable
sections of the notice.

1. CMS has accepted this
suggestion and replaced the
reference to a page number
with a reference to the
name of the applicable
section.
2. CMs has included language
in the notice instructions
that plans may remove the
fast appeals section if the
notice is for a payment
denial.
3. CMS did not accept this
suggestion. Language was
inserted to remain
compliant with request for
alternative format
requirements of Section 504
of the Rehabilitation Act.
4. Issue 1: CMS has accepted
this comment and has
removed the language “If
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appear on a different page for each member depending
on the number of procedures.

this is impossible” in the
instructions.

“State Fair Hearing: Ask for a State Fair Hearing within
( ) days of the date of this notice. You have up to ( )
days if you have a good reason for being late. See
section within letter titled How to ask for a State Fair
Hearing of this notice for information about how to ask
for a State Fair Hearing.”

Issue 2: CMS has not
accepted this suggestion.
Current regulations require
that written notification of
adverse initial
determinations must be
readable and
understandable to the
enrollee. This would include
any information in free text
fields, including the denial
rationale.

2. Section, When to ask for an appeal:
The narrative does not provide enough information to
let members know that they are not entitled to an
expedited appeal when a request for payment of
service is already provided.
In order to avoid member abrasion/complaints, we
recommend that CMS amend the language to indicate
the following instead in the “How to ask for an Appeal”
section of the notice.
Whether you want a Standard or Fast Appeal (for a Fast
Appeal, explain why you need one). Please note that if
request for payment of a service has already been
provided, your claim cannot be reviewed as an
expedited reconsideration.
3. Added 504 language:
Directing members to 1--800-MEDICARE or to email.
[email protected] when the correspondence was
generated by the plan can cause abrasion to members,
since CMS would not have the information related to
the claim to properly discuss with members.

5. CMS acknowledges this
comment and has made
revisions to the instructions
under the “Why did we deny
your request” section. The
instructions now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.

We recommend that rather than directing members to
1--800-MEDICARE or to email [email protected],
CMS should add the following language disclaimer
already provided in the Medicare Marketing Guidelines
that speaks to this.
“ This information is available for free in other
languages. Please call our customer service number at
[insert customer service and TTY numbers, and hours of
operation].”
4. Notice delivered in Spanish:
The instructions include the following:
“When the Spanish-language version of this notice is
used, the Medicare health plan must make insertions on
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the notice in Spanish. If this is impossible, additional
steps need to be taken to ensure that the enrollee
comprehends the content of the notice.”
Issue 1:
The language within the same narrative appears to be
contradictory “must make”/ “if this is impossible.”
Recommendation 1:
We recommend that the instructions be changed to the
following instead:” When the Spanish-language version
of this notice is used, the Medicare health plan should
make insertions on the notice in Spanish. If this is
impossible, additional steps need to be taken to ensure
that the enrollee comprehends the content of the
notice.
Issue 2:
This can be a massive undertaking when you Consider
the share number of procedure codes (CPTs, HCPCs and
Revenue codes) that are provided for denied services
on claims, the CARC/RARC codes & which provide
descriptions for the denial, and the Claim Adjustment
Reason Code (CARC) – 355 codes Remittance
Adjustment Reason Code (RARC) – 1,041 codes.
Recommendation 2:
As an alternative to CMS’ proposal about making
insertions in Spanish on the notice, we recommend that
plans be allowed to plans insert the following
alternative language disclaimer:
This information is available for free in other languages.
Please contact Customer Service at [insert customer
service and TTY numbers, and hours of operation; and
insert as applicable “Customer Service also has free
language interpreter services available for non-English
speakers.”]
5. Why did we deny your request section:
The instructions state, “For plans that manage both
Medicare and Medicaid benefits (e.g., integrated
Dual Special Needs Plans) --If a service/item is
denied under Medicare but can be covered under
Medicaid, the free text field should contain an
explanation that the service/item will be covered
under the enrollee’s Medicaid benefits (in addition
to the required explanation related to the Medicare
denial).”
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The suggestion to add an explanation that the service
can be covered by Medicaid may be premature and
inaccurate since given the timing of the back-end
process, plans are not sure if the issue
identified/highlighted will be covered by Medicaid.

Instructions

1

We recommend that CMS revise the instructions to
indicate the following instead.
[Medicare doesn’t cover the denied medical service(s)
as indicated above. Although we have denied this
service(s) under Medicare benefits, because you have
Medicaid coverage with us, this service(s) may be
covered under Medicaid. And processed under your
Medicaid health benefits.]
Minnesota Dept. of Human Services, Gretchen Ulbee
Why did we deny your request section:
The revised instructions appear to require Medicare
Advantage health plans that have an arrangement with
the state to cover Medicaid services to issue Medicare
denial notice to beneficiaries who will receive the
covered service from the same plan under Medicaid.
Such notices will only cause confusion and uncertainty.
We are concerned because these new instructions
imply that a notice needs to be sent by the health plan
every time a service/item is covered by Medicaid and
not Medicare. Minnesota health plans participating in
our Medicare-Medicaid demonstration issue only a
single notice of denial and issue denials only when the
health plan will not provide the service. This process
has worked very well to assist beneficiaries to get the
actionable information they need if they will not be
receiving a service. This will result in an avalanche of
confusing and unhelpful mail for beneficiaries.

1. CMS acknowledges the
changes in the instructions
regarding when CMS-10003
should be issued has the
potential to cause member
confusion. Therefore, we
have made appropriate
revisions the instructions.
The instructions now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.

When Minnesota created MSHO, we worked with the
health plans to create and implement an integrated
benefit determination process. The health plan would
first determine if Medicare would cover the service and
then if Medicaid would cover the service. A denial
notice would only be issued to the member if the plan
was denying or not paying for a service under either
Medicare or Medicaid. It was determined that to send
a Medicare denial notice when in fact the plan would
be covering the service under Medicaid would be
confusing to the member as there was no action the
member needed to take. No appeal was necessary as
the member had already received authorization for the
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service or the service already provided was paid for by
the health plan.
The new instructions to this notice seems to ignore the
fact the state has certain requirements regarding the
authorization and denial of these services including
what notices are to be sent and when. When the IDN
was initially created and issued, Medicaid services were
taken into account and the process of issuing a single
notice only when the health plan is not providing the
service regardless of Medicare or Medicaid has worked
very well. There are cases of overlap in some services
such as skilled nursing and if the service is in fact
moving from Medicare covered to Medicaid covered, a
notice is to be issued as the service is a different level
of service. We have been able to work with our health
plans to assure that in these instances, appropriate
notices are issued.
If implemented as they appear, these instructions
would result in possibly millions of new confusing and
duplicative notices to members. According to these
new instructions, the health plan would also be
required to send the IDN notifying the enrollee that the
services were denied under Medicare. This second
notice serves no purpose except to confuse the
member regarding whether services that were
authorized will be covered.
The burden of time and cost estimates that CMS
provided for this provision for plans, states and
members are vastly underrepresented in the
documentation. It will result in development of new
processes with attached systems costs, extreme
increase in paperwork, an increase in time spent
answering confused member’s calls because of
receiving notices that require no action on behalf of the
member but imply a negative action on behalf of the
health plan and millions of new notices being issued.
Such a far-reaching policy change should not be implied
by adding unclear instructions to a form.
Please clarify that these instructions do not apply to
Medicaid-only services that would never be covered
under Medicare. The proposed instructions should be
revised to apply only when there is a clear overlap of
Medicare and Medicaid
services such as skilled nursing. No Medicare denials
should be issued for any services clearly covered only
by Medicaid such as personal care attendant and
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Notice,
Instructions

Section 1915(c) home and community-based waiver
services.
Justice in Aging, Georgia Burke

1. CMS acknowledges the
changes in the instructions
regarding when CMS-10003
Form Instructions for the Notice of Denial of Medical
should be issued has the
Coverage:
potential to cause member
confusion and we have
1. Why did we deny your request?
made appropriate revisions
We are concerned that a portion of this section creates
the instructions. However,
confusion and alarm and does not serve a regulatory
CMS does not believe an
purpose. The section instructs plans that manage both
additional notice should be
Medicare and Medicaid benefits to send a denial notice
created. The instructions
even when the plan has approved the service as a
now state:
Medicaid benefit. A beneficiary who receives a denial
notice with a bold “Notice of Denial of Medical
-plans must determine if
Coverage,” heading, along with appeal instructions, is
services are covered under
unlikely to understand the service is authorized. At the
the plan’s Medicare and/or
very least, the notice is likely to prompt an unnecessary
Medicaid benefit;
call to the plan to get clarification. From a beneficiary’s
-the criteria plans are to
point of view, there is no purpose to be served by
take into consideration
getting the notice. The beneficiary will get the service
when making that
and will get it through the plan. Moreover, there is no
determination; and
regulation requiring a plan to send a denial notice when
-clarification on the
the plan has actually authorized the service. The most
circumstances under which
directly relevant regulatory section, 42 CFR 422.568,
the notice should be issued.
requires a notice if an organization “decides to deny
2. Any translated version of
service or payment in whole or in part . . .” but does not
standardized notices must
require a notice when, in fact, a service request has
be OMB-approved. At this
been fully approved.
time, CMS has only created
Spanish-language version of
CMS-10003-NDMCP that is
This requirement runs counter to the goal of
OMB approved.
integrating Medicare and Medicaid care and services.
3. CMS believes the free text
It fragments the beneficiary experience, causing
fields are an appropriate
confusion and unnecessary alarm. We ask that it be
place for health plans to
removed from the instructions.
insert the date services will
end, therefore, we are not
making changes based on
If, in fact, there are situations where approval of a
this suggestion.
service under Medicaid, though constituting full
approval of the service requested, would in some way
4. We did not accept the
disadvantage the beneficiary compared to approval of
commenter’s suggestion to
the service under Medicare, those situations raise
change the section “How to
serious questions about whether D-SNPs are
keep your services while we
functioning as envisioned and as promoted by the
review your case”. The
plans. D-SNP members are supposed to be spared the
current language in this
complexities of navigating the intersection of Medicare
section includes important
and Medicaid benefits.
information about appeal
rights that apply to both
10

We urge CMS to look to structural remedies to those
situations beyond what could be achieved by individual
appeals. If such cases exist and until they are remedied
globally, then a different notice should be designed for
those, hopefully rare, circumstances. The notice should
have a different heading and different leading
sentence, both making it clear that the beneficiary can
get the services requested. Plans should be required to
include a specific explanation in the notice of why the
beneficiary might be disadvantaged by the denial of
Medicare coverage for the service.
Without some guideposts, beneficiaries would have no
way to understand what they might be losing even
though they are receiving approval for all they have
requested and would have no reasonable basis for
deciding whether to pursue a Medicare appeal.
2. Translations and Multi-language inserts
We do not see instructions about language or disability
notices, though there is reference to a Spanish version
of the notice.
We ask that the instructions require that plans:
- Provide a translated copy of this notice to any plan
member speaking a language that meets the threshold
set by 42 CFR 422.2264(e) for marketing documents
and, for individuals in plans that manage both their
Medicare and Medicaid benefits, in any additional
language that meets a different threshold set by the
relevant state Medicaid agency.
- Include a multi-language insert in all languages in the
current Medicare insert, (see Medicare Marketing
Guidelines, https://www.cms.gov/Medicare/HealthPlans/ManagedCareMarketing/Downloads/2016Medicare-Marketing-GuidelinesUpdated.pdf at 30.5.1) and, for individuals in plans that
manage both their Medicare and Medicaid benefits, in
any additional languages that may be required by the
relevant state Medicaid agency for Medicaid
communications. We suggest the following text:
“We have free interpreter services to answer any
questions you may have about this letter. To get an
interpreter, just call us at [1-xxx-xxx-xxxx]. Someone
who speaks [language] can help you. This is a free
service.”
Note that this would require only a slight change of one
phrase in the current multi-language insert already
included with marketing materials.

5.

6.

7.

8.

9.

plan appeals and state fair
hearings.
CMS believes this
information is appropriately
placed in the sections titled
“How to ask for an appeal
with {Health plan name} and
“How to ask for a Medicaid
State Fair Hearing” on page
3 of the notice.
Because this comment is
related to coordination
between CMS and each
state Medicaid agency, it is
outside of the scope of this
PRA package.
Use of CMS-10003 extends
to plans outside of the
financial alignment
demonstration. The
enrollee’s first point of
contact should be the health
plan itself. CMS will
maintain the order of the
phone numbers listed in the
“Get more help &
information” section as well
as keep the Elder Health
Locator contact information,
which can assisting with
finding additional assistance
to beneficiaries with
disabilities within their
community. CMS has added
a bracketed section for state
or local aging/disability
resources contact
information, where SHIP
contact information can be
inserted.
CMS has added language on
page 4 of the denial notice
that states beneficiaries can
request this publication in
an alternate format.
The IDN is an OMB
approved form and can only
be modified in the free-text
11

3. Your Request was denied.
We suggest including a statement explaining when the
denial will be effective.
In New York’s Fully Integrated Dual Advantage (FIDA)
program, the Coverage Determination Notice (CDN)
opens with:
1) Your Services were (denied) and you can appeal this
decision.
2) The decision will take effect on: .
We suggest replicating the New York format in the IDN.

fields, as appropriate. The
plan cannot include
additional forms with the
IDN.

4. How to keep your services while we review your
case:
This section should only be included in the notice when
the denial actually involves stopping, reducing or
suspending a service. It is confusing to include it in
other cases.
The wording should change from “If we’re stopping . . .”
to “Because we’re stopping . . .” This section should be
inserted as a text box or highlighted.
5. You have a right to appeal your decision.
We suggest including the phone number for the plan,
the State Fair Hearing (SFH) office and the inclusion of
an e-mail address where the individual can send the
appeal to the plan for both the standard and fast
appeal.
6.How to ask for Medicaid State Hearing:
In states where individuals can request a SFH
simultaneously or before a plan review, it would be
much less confusing if the individual has the option of
creating one appeal request and submitting it to one
address. The beneficiary can tell the plan which appeal
route or routes the beneficiary wishes to follow.
Having a form for this purpose attached to the notice
would facilitate this process. Requiring the individual
to create two separate documents and submit them to
two separate addresses is not an integrated process.
7. Get help & more information section
When this notice is used by plans in the financial
alignment demonstration, the first phone number and
website listed should be the State Dual Eligible
Demonstration Ombudsman Program should be the
first contact listed after the plan itself. We also suggest
removing the information for the Elder Care Locator, as
12

that contact is not appropriate or particularly helpful
for appeals assistance, and substituting the number for
the SHIP program in the plan’s service
area.
8. Notice of availability in other formats and of
languages services
A notice should appear prominently on the letter
stating that the recipient can request the notice in
other formats such as Braille or large print. As we
stated above, we also request the inclusion of a multilanguage insert announcing the availability of
interpreter assistance. If the insert cannot be
immediately required, we ask at a minimum that there
be a notice in English on the letter stating that
interpreter assistance is available.

Instructions

1

9. Appeal Form
We strongly recommend requiring plans to enclose an
appeal form in each IDN. Beneficiaries should be
encouraged, but not required, to use the form for the
appeal. Having a form with boxes to check and blanks
to fill greatly simplifies the start of an appeal for the
beneficiary and also simplifies administration of
appeals for the plan. It is much less intimidating,
particularly for low literacy, limited-English proficient
beneficiaries, than having to draft an appeal request
from scratch. In addition to including the paper form,
the plan should make the form available on its website
with an e-mail address for submission. The form should
allow for a State Fair Hearing option, if applicable, and
have a box to request aid paid pending. The New York
FIDA Appeal Request Form is a good model. Note
especially that the New York form has boxes to request
interpreter or disability assistance.
PRIDE-CHCS (Promoting Integrated Care for Dual
Eligibles-Center for Health Care Strategies), Brianna
Ensslin
Why did we deny your request? section:
PRIDE health plans support use of the IDN and do not
have concerns about the form itself; however, we are
concerned about new language that appears in the
instructions for the section entitled why did we deny
your request? The following outlines the PRIDE plans'
concerns regarding the proposed change, and offers a
question for CMS' consideration. The proposed new
required text will result in:

1. CMS acknowledges the
changes in the
instructions regarding
when CMS-10003
should be issued has the
potential to cause
member confusion and
increase administrative
burdens for plansincluding increased call
volume and mailing
costs. Therefore, we
have made appropriate
13

1. Member confusion and unnecessary appeals.
Required text would note a service is not covered here
(under Medicare), but is covered there (under
Medicaid), and the very next section provides
information on appeals. There are several issues with
this.
The new instructions seem to assume that all requests
for service are treated as requests for Medicare
services, even if those services are exclusively
Medicaid-covered services (such as non-emergency
transportation, home and community-based services or
personal care assistance) and would never be covered
by Medicare. We believe this is "Medicare-centric" and
wonder why this is necessary in the context of an
integrated denial notice. If a service is covered under
Medicaid, there is no reason to appeal. We anticipate
an increase in unnecessary appeals filings, along with
increased administrative costs. The proposed changes
do not take into account the fact that many plans have
a separate contract with the state to provide a different
set of services under Medicaid.

revisions the
instructions. The
instructions now state:
-plans must determine if
services are covered
under the plan’s
Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under
which the notice should
be issued.

2. Significant administrative burden to health plans that
must update programming in systems to accommodate
confusing text.
3. Increased mailing costs to send denials that are not
needed because services are Medicaid covered.
4. Increased call volume to customer service centers,
and subsequent challenges explaining why a member
received a denial notice, when services can actually be
provided/charges will be paid.
Specific to dental services, because the majority of
dental services are only covered under Medicaid, full
dual eligibles will receive a denial notice for almost all
of their dental services. Again, this will result in
confusion and increased administrative costs.
Currently, Medicaid only services (personal care
assistants, private duty nursing, Elderly Waiver services,
nursing facility services, dental, vision, transportation,
certain mental health services (residential treatment),
and home care therapies) are not reported to CMS.
However, if health plans start issuing the CMS-10003 to
explain why a service was approved as a state benefit,
is the expectation that plans would then begin
reporting on all services?
14

Notice

Notice,
Instructions

2,4

We encourage CMS to reconsider requiring the new
language for the reasons noted.
UnitedHealthcare, Shannon Schuster

1. CMS believes the
language is in the
appropriate sections of
the notice.
2. CMS agrees and has
included language in the
notice instructions that
plans may remove the
fast appeals section if
the notice is for a
payment denial.
3. CMS has inserted this
language to remain
compliant with request
for alternative format
requirements of Section
504 of the
Rehabilitation Act.

1. Important Information About Your Appeal Rights
UHC has concerns regarding appeal rights within
the Integrated Denial Notice (IDN). The Standard
Appeal section states “We’ll give you a written
decision on a standard appeal within 30 days
[Insert timeframe for standard internal plan
Medicaid appeals, if different] after we get your
appeal.” Later, the Fast Appeal section states both
"...by waiting up to 30 days for a decision" and "If
we don’t give you a fast appeal, we’ll give you a
decision within 30 days."
UHC believes that the bracketed statement of
"[Insert timeframe for standard internal plan
Medicaid appeals, if different]" should be added to
both instances under the Fast Appeal section to
ensure that this timeframe is consistent with the
plan Medicaid appeals timeframe.
2. Additionally, UHC asks that CMS provide detailed
versioning instructions between the pre- and postappeal language. For example, there is a postservice version of the IDN that is sent to members
when payment has been denied, which means that
the services have been rendered. Therefore, the
pre-service appeal language regarding the 30 day
timeframe should not be included as it does not
apply. We believe that the post-service IDNs
should contain only the 60 day timetable language.
Furthermore, any reference to "Fast Appeal" should
be deleted for the
post-service version of the IDN.
3. Alternate Formats
UHC has concerns with CMS’ statement regarding
the request of alternative formats. The IDN
currently states “To request this publication in an
alternative format, please call 1-800- MEDICARE or
email: [email protected].” We do not
believe that contacting CMS for an alternative
format is appropriate in this case.
We believe that the applicable health plan should
be contacted when requesting an alternative
format of any document.
Medicare Rights Center, Casey Schwarz
1. CMS agrees and has
1. Provide additional guidance on the ‘free text’
provided additional
denial reasons section: We continue to encourage
clarification in the notice
15

2.

3.

4.

5.

CMS to develop model language for the ‘free text’
portion of the denial notice for some of the more
common reasons for a denial, like out-of-network
services, and to review randomly selected denial
notices to ensure that the ‘free text’ sections are
clear, readable, and accurate.
Require more translation and multi-language
inserts: We strongly support the requirement in
the Notice Instructions that plans translate the
‘free text’ portions of the notice if the notice is
delivered in Spanish. On translation, we urge CMS
to go further and require that plans provide denial
notices in the predominately spoken languages of
their service areas. CMS should also require the
inclusion of a multi-language insert with
information about translation services for other
languages.
Why did we deny your request section: First, we
are pleased that the notice affirms that dually
eligible beneficiaries must receive notice of the
denial of their service under Medicare, even if the
plan will pay benefits under Medicaid. We are
concerned, however, that simply including this
information in the section titled “Why we denied
your request” is insufficient and may be confusing.
We suggest that, in such situations, the headings
be changed to reflect that the request is denied
under Medicare but covered under the Medicaid
benefit. In addition, we suggest adding language
that makes clear to the beneficiary that while
Medicaid will pay for the given service or
treatment, the beneficiary has the right to appeal
the decision that Medicare will no longer pay. We
suggest including a specific explanation of this in
the form instructions, rather than allowing plans to
craft their own language in the ‘free text’ section.
“You have the right to appeal our decision,”
section: We strongly support the requirement to
include accurate and appropriate information
about State Medicaid fair hearing rights and
Medicaid Managed Care appeal timelines where
the denial includes Medicaid benefits. The plan—
not the beneficiary—should be responsible for
identifying which services are covered under which
programs and should accurately and reliably direct
the beneficiary to the correct appeals framework.
Section titled “Plan Appeal,” We also suggest that
the content in the “plan appeal” section parallel

2.

3.

4.
5.

6.

7.

instructions regarding what
appropriate denial rationale
must include.
Any translated version of
standardized notices must
be OMB-approved. At this
time, CMS has only created
Spanish-language version of
CMS-10003-NDMCP that is
OMB approved.
CMS acknowledges the
changes in the instructions
regarding when CMS-10003
should be issued has the
potential to cause member
confusion. CMS has
included sample language
for plans within the
instructions and have also
made appropriate revisions
the instructions. In
addition, the instructions
now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.
CMS agrees and thanks you
for your comment.
CMS accepts this suggestion
and has inserted language
that refers to the
appropriate section on how
to ask for an appeal.
Language is included that
instructs plans to insert
“State Fair Hearing”, if
applicable. CMS will keep
the current sub-heading.
CMS does not believe that
within the context of this
16

6.

7.

8.

9.

Notice

1-2

the language included in the section titled, “State
Fair Hearing.” The section on fair hearings ends
with “see page {xx} for information about how to
file…,” and we suggest adding the same language
“see page {xx}…” at the end of the section on plan
appeals.
In addition, we recommend that the sub-heading
“How to keep your services while we review your
case” include reference to the fair hearing so that
it is clear to the beneficiary that the review only
takes place with a fair hearing. A suggested
rewrite of this heading could read, “How to keep
your services during your appeal and/or fair
hearing.”
Section titled, “If you want someone else to act for
you”: We suggest that the heading more clearly
indicate that someone else may represent you
during your appeal and that within the paragraph
the representation be expressly linked to the
purpose of the appeal. A suggested rewrite of this
title could read,” If you want someone else to
represent you during your appeal.”
Section titled “Important Information About Your
Appeal Rights”: While we strongly support
including information about fair hearing rights, the
inclusion of this information makes the heading
“there are two types of appeals” somewhat
confusing for consumers. We encourage CMS to
consider changing this language to “There are two
timelines for plan appeals” or “You can ask us for a
Standard or Fast Appeal”.
Section titled, “How to ask for a Medicaid State
Fair Hearing” We recommend that this section
restate the information about aid continuing and
the timeline in order to receive aid continuing.

Center for Medicare Advocacy, Mary Ashkar
1. Your request was denied:
Recommended change-When a Part C Medicare
health plan decides to discontinue or reduce a
previously authorized ongoing course of treatment
the NDMPC should give the effective date coverage
will end. Instructions should require that the last
date of coverage or discharge date be listed.
Rationale for recommended change: This change to
the NDMPC would make it consistent with the

notice there are any implied
circumstances when a
representative could act for
a beneficiary outside of an
appeal. CMS does not agree
that this section needs
further clarification.
8. CMS believes the current
language in the heading
“There are two types of
appeals with {health plan}”
appropriately identifies the
two types are for a plan
level appeal.
9. CMS believes language in
the “You have the right to
appeal our decision” section
is appropriate for
information regarding
continuing services and CMS
does not believe it should be
included in multiple
sections.

1. CMS believes the free text
fields are an appropriate
place for health plans to
insert the date services will
end, therefore, we are not
making changes based on
this suggestion.
2. CMS believes adding a
placeholder for a deadline
date could result in plans to
making unnecessary system
changes to accommodate
17

Notice of Medicare Non-Coverage which gives the
effective date coverage of current services will end.
2. You have the right to appeal our decision:
· Recommended change #1-The revised NDMPC
should include the date by which an appeal must
be made. For example, “Ask {health plan name} for
an appeal within 60 days [Insert State Medicaid
timeframe for internal plan appeals, if different] of
the date of this notice. We must receive your
appeal by: [Insert date when an
appeal must be received].”
Rationale for recommended change #1: The Medicare
Summary Notice (MSN) used for those who are in the
traditional Medicare program includes a date in a box
when an appeal must be received. Although the appeal
tracks for traditional Medicare and Medicare Part C
differ, the MSN serves the same purpose as the
NDMPC, which is to give Medicare beneficiaries
information in a meaningful and understandable way.
People who are receiving a NDMPC may be in a health
care crisis and including this information, in the same
way as the MSN, ensures that there is no
misunderstanding regarding the deadline for an appeal.

3.

4.

5.

3. Recommended change #2: The NDMPC states that
“[w]e can give you more time if you have a good
6.
reason for missing the deadline.” This language is
misleading. The NDMPC should be revised to state:
“It is important that you appeal the decision within
the 60-day period. If, however, you miss the 60day period in which to file an appeal you may
request an extension of the timeframe. The
request for reconsideration and the request for an
extension of the timeframe must be in writing and
must clearly state why the request for
reconsideration was not filed on time. It is within
the plan’s discretion to accept or deny the request
for an extension.” Rational for recommended
change #2: 42 CFR §422.582 allows an extension of
the timeframe for filing a request for
reconsideration if the enrollee can show good
cause for the delay. The request must be in writing
and must state the reason why the request was not
filed on time. The current NDMPC does not instruct
enrollees to send their request for an extension in

this type of requirement. In
addition, an extension could
be applied, changing the
date and causing confusion
for the beneficiary.
CMS believes the
recommended change is not
in easily understandable
language for the beneficiary
and that the current
language is understandable
and refers beneficiaries to
the plan to get further
instruction on how to file an
extension.
CMS believes the term
“expedited” as referred to in
Medicare regulations, is
primarily used by health
plans and providers and is
not considered
understandable language
for the beneficiary.
CMs agrees and has
included language in the
notice instructions that
plans may remove the fast
appeals section if the notice
is for a payment denial.
The IDN is an OMB
approved form and can only
be modified in the free-text
fields, as appropriate. The
plan cannot include
additional forms with the
IDN.

18

writing. In addition, it is our experience that
enrollees who receive this NDMPC are often
experiencing a health care crisis, often miss the
deadline for filing an appeal, and thus, need an
extension to file an appeal. It is also our experience
that when an enrollee does appeal and requests an
extension, the health plan often denies the request.
The importance of appealing within 60 days and
the fact that an extension of time to appeal is not
guaranteed should be underscored.
4. Section entitled Important Information About Your
Appeal Rights
Recommended change #1- Instead of calling it a
Fast Appeal, the NDMPC should refer to an
Expedited or Fast Appeal. Rationale for
recommended change #1: The Medicare
regulations as well as the Medicare Managed Care
Manual refer to this type of appeal as an
“Expedited” appeal request. Keeping the language
used in Medicare regulations, Manual provisions
and the NDMPC consistent
would help to minimize any potential confusion.
5. Recommended change #2: The NDMPC should
make it clear that a Part C Medicare organization
will expedite a request for appeal that involves
specific issues including:
§ The Part C organization’s refusal to provide or pay
for services, in
whole or in part, including the type or level of
services, that the
enrollee believes should be furnished or arranged
for by the Part C
organization; and
§ Reduction, or premature discontinuation of a
previously authorized ongoing course of treatment.
In addition, the NDMPC should state in the
description of an expedited appeal that a Part C
Medicare organization will not expedite an appeal
request for payment of services already furnished.
Rationale for recommended change #2: 42 CFR
§422.584(a) only allows expedited appeals for
certain issues. The description of a standard
appeals says that if an appeal is for payment of a
service already received, a decision will be given
within 60 days. However the description of a “Fast
Appeal” makes it sound like an enrollee will
19

automatically get a fast appeal if the doctor asks for
one or supports a request regardless of what type
of appeal it is.

Instructions,
Notice

6. Section entitled How to ask for an appeal {health
plan name}
Recommended change: The NDMPC should include
a model form for enrollees to use when filing an
appeal. Rationale for recommended change: Those
who have traditional Medicare, rather than a Part C
Medicare plan, are given appeal forms at every
stage of the appeals process. The redesigned
Medicare Summary Notice has a form on
the last page of the notice with step-by-step
directions on how to fill out the form and request a
redetermination decision. The redetermination
decision includes a Reconsideration Request Form
that an individual can use to request an appeal to
the next level. The reconsideration decision
includes a link to a form to be used when
requesting an Administrative Law Judge hearing.
Often times those who receive notices regarding
their health care are in crisis and including a form
to use when appealing will ensure all required
information is included with an appeal. Also an
appeal form is more likely to be noticed by a Part C
Medicare organization as an appeal, rather than a
grievance or a complaint, which are handled and
processed differently.
Health Care Service Corporation, Sue Rohan
1. Section titled “Why Did We Deny Your Request?”
CMS has added a paragraph in the instructions for the
Notice of Denial of Medical Coverage (or Payment) in
the Why did we deny your request section. It appears
that this instruction would require plans to send the
Notice for any service that is exclusively a Medicaidcovered service that would never be covered by
Medicare. HCSC is concerned that the new instruction
is placing a new requirement on plans that would
greatly expand the use of the Notice, requiring it to be
issued every time a Medicaid service is covered in a
Medicare plan that manages the member’s Medicaid
benefits. This instruction would require mailing
millions of Notices, especially since Medicaid-only
covered services are often high frequency services such
as personal care, transportation and interpreter
services. The approach encompassed in this new

1. CMS acknowledges the
changes in the
instructions regarding
when CMS-10003
should be issued has the
potential to increase
member confusion,
increase administrative
burden for plans and
increase the number of
appeals. Therefore, we
have made appropriate
revisions the
instructions. The
instructions now state:
-plans must determine if
services are covered
under the plan’s
20

instruction seems contrary to what CMS, States, and
plans are striving to achieve when offering plans that
integrate the Medicare and Medicaid programs to
better serve the member. This new requirement could
result in significant confusion and stress for members.
It is likely that plans would see a commensurate
increase in member inquiries, complaints, and appeals
due to confusion. This could create a costly
administrative burden on plans and negatively impact
Star Ratings.
HCSC recommends that CMS eliminate the new
instruction to avoid member confusion and
administrative complexity. Alternatively, we
recommend that CMS (1) clarify the new instruction
applies only in situations where a service or item could
be covered by either Medicare or Medicaid, but under
different criteria and (2) exclude services that are
covered only by Medicaid.
America's Health Insurance Plans, Mark Hamelburg
1. Proposed Instruction for Plans that Manage both
Medicare and Medicaid Benefits (Why did we deny
your request? instructions). CMS is proposing in
the form instructions for the draft notice add an
instruction that would require plans that manage
both Medicare and Medicaid benefits to include an
explanation of coverage in the free text field when
a service/item is denied under Medicare but is
covered under the beneficiary’s Medicaid benefits.
We have several concerns with this proposed
additional instruction when a benefit is denied
under Medicare but fully covered under Medicaid.
First, we are very concerned that language stating
coverage for a service/item is denied under one
payer and covered by another payer would be very
confusing for beneficiaries and most likely generate
beneficiary inquiries and/or appeals. We believe
the primary goal for the notice of denial of medical
coverage should be to provide a beneficiary with
information he or she needs to appeal a service or
item denied in whole or in part. When the
beneficiary receives the requested coverage,
details indicating that the benefit is covered under
Medicaid only (e.g., long term services and
supports) does not appear to provide any useful
information since no appeal would be required.
Further, CMS’ proposed requirement should also

Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under
which the notice should
be issued.

3. CMS acknowledges the
changes in the instructions
regarding when CMS-10003
should be issued has the
potential to increase
member confusion.
Therefore, we have made
appropriate revisions the
instructions. The
instructions now state:
-plans must determine if
services are covered under
the plan’s Medicare and/or
Medicaid benefit;
-the criteria plans are to
take into consideration
when making that
determination; and
-clarification on the
circumstances under which
the notice should be issued.
4. CMS has accepted this
suggestion and replaced the
reference to a page number
with a reference to the
name of the applicable
section.

21

align with the agency’s commitment as indicated in
the CY 2016 Call Letter, to support efforts to
provide more seamless integrated Medicare and
Medicaid benefits and better communicate these
benefits to dually eligible beneficiaries. The
agency’s proposal however, is inconsistent with
treating the benefits as an integrated whole.
Lastly, we note that a number of states have
worked with plans to develop coordinated
messages for beneficiaries that they believe would
most effectively convey information about
coverage and we believe that CMS’ proposal would
interfere with those established processes. We
therefore recommend that CMS not move forward
with its proposal. If CMS is interested in exploring
ways to improve notices for dually eligible
beneficiaries, we recommend that the agency
engage in discussions with plans to ensure that the
issues raised above as well as others underlying
such an effort are fully considered.
2. Reference to Medicaid State Fair Hearing Section.
At the top of page 2 of the draft notice under the
section titled, “You have the right to appeal our
decision,” CMS is proposing to add language that
would refer dually eligible beneficiaries to the page
of the denial notice that includes information about
how these beneficiaries can request a Medicaid
State Fair Hearing. Instead of requiring the
inclusion of a particular page number, which can
vary depending on the length of the notice, we
believe that plans should be permitted to reference
the actual heading, “How to ask for a Medicaid
State Fair Hearing,” for the section in the denial
notice that includes this information. We
recommend that CMS revise this section to reflect
such an option.

22