CMS-10338 Internal Adverse Benefit Determination

Model Notice of Final Internal Adverse Benefit Determination – Revised as of June 22, 2011

Date of Notice
Name of Plan
Address

Telephone/Fax
Website/Email Address

This document contains important information that you should retain for your records.
This document serves as notice of a final internal adverse benefit determination. We have declined to
provide benefits, in whole or in part, for the requested treatment or service described below. If you
think this determination was made in error, you may have the right to appeal (see the back of this page
for information about your appeal rights).
Internal Appeal Case Details:
Patient Name:
ID Number:
Address: (street, county, state, zip)
Claim #:

Date of Service:

Provider:
Reason for Upholding Denial (in whole or in part):
Amt.
Charged

Allowed
Amt.

Other
Insurance

Deductible Co-pay

Coinsurance Other Amts. Amt. Paid
Not Covered

YTD Credit toward Deductible:

YTD Credit toward Out-of-Pocket Maximum:

Description of Service:

Denial Codes:

[If denial is not related to a specific claim, only name and ID number need to be included in the box.
The reason for the denial would need to be clear in the narrative below.]
Background Information: Describe facts of the case including type of appeal and date appeal filed.
Final Internal Adverse Benefit Determination: State that adverse benefit determination has been
upheld. List all documents and statements that were reviewed to make this final internal adverse
benefit determination.
Findings: Discuss the reason or reasons for the final internal adverse benefit determination.
[Insert language assistance disclosure here, if applicable.

SPANISH (Español): Para obtener asistencia en Español, llame al [insert telephone number].

TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].
CHINESE (中文):

如果需要中文的帮助，请拨打这个号码 [insert telephone number].
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].

OMB Control Number 0938-1099

Model Notice of Final Internal Adverse Benefit Determination – Revised as of June 22, 2011

Important Information about Your Rights to External Review
What if I need help understanding this denial?
Contact us [insert contact information] if you need
assistance understanding this notice or our decision
to deny you a service or coverage.
What if I don’t agree with this decision? For
certain types of claims, you are entitled to request
an independent, external review of our decision.
Contact [insert external review contact information]
with any questions on your rights to external
review. [For insured coverage, insert: If your claim
is not eligible for independent external review but
you still disagree with the denial, your state
insurance regulator may be able to help to resolve
the dispute.] See the “Other resources section” of
this form for help filing a request for external
review.

begin the process (such as by phone, fax, electronic
submission, etc.)].
Who may file a request for external review?
You or someone you name to act for you (your
authorized representative) may file a request for
external review. [Insert information on how to
designate an authorized representative.]
Can I provide additional information about my
claim? Yes, once your external review is initiated,
you will receive instructions on how to supply
additional information.
Can I request copies of information relevant to
my claim? Yes, you may request copies (free of
charge) by contacting us at [insert contact
information].

How do I file a request for external review?
Complete the bottom of this page, make a copy, and
send this document to {insert address}.] [or] [insert
alternative instructions.] See also the “Other
resources to help you” section of this form for
assistance filing a request for external review.

What happens next? If you request an external
review, an independent organization will review our
decision and provide you with a written
determination. If this organization decides to
overturn our decision, we will provide coverage or
payment for your health care item or service.

What if my situation is urgent? If your situation
meets the definition of urgent under the law, the
external review of your claim will be conducted as
expeditiously as possible. Generally, an urgent
situation is one in which your health may be in
serious jeopardy or, in the opinion of your
physician, you may experience pain that cannot be
adequately controlled while you wait for a decision
on the external review of your claim. If you believe
your situation is urgent, you may request an
expedited external review by [insert instructions to

Other resources to help you: For questions about
your rights, this notice, or for assistance, you can
contact: [if coverage is group health plan coverage,
insert: the Employee Benefits Security
Administration at 1-866-444-EBSA (3272)]
[and/or] [if coverage is insured, insert State
Department of Insurance contact information].
[Insert, if applicable in your state: Additionally, a
consumer assistance program can help you file your
appeal. Contact:[insert contact information].]

NAME OF PERSON FILING REQUEST FOR EXTERNAL REVIEW: _________________________
Circle one:Covered person  Patient  Authorized Representative
Contact information of person filing request for external review (if different from patient)
Address: _________________ Daytime phone:________________ Email:_______________
If person filing request for external review is other than patient, patient must indicate authorization by
signing here: _______________________________________________
Are you requesting an urgent review? Yes  No
Briefly describe why you disagree with this decision (you may attach additional information, such as a
physician’s letter, bills, medical records, or other documents to support your claim):
______________________________________________________________________________
______________________________________________________________________________
Send this form and your denial notice to: [Insert name and contact information]
Be certain to keep copies of this form, your denial notice, and all documents and correspondence related
to this claim.