Section 1852(g)(1)(B) of the Social
Security Act (SSA) requires Medicare health plans to provide
enrollees with a written notice in understandable language that
explains the plan's reasons for denying a request for a service or
payment for a service the enrollee has already received. The
written notice must also include a description of the applicable
appeals processes. Regulatory authority for this notice is set
forth in Subpart M of Part 422 at 42 CFR 422.568, 422.572,
417.600(b), and 417.840. Section 1932 of the Social Security Act
(SSA) sets forth requirements for Medicaid managed care plans,
including beneficiary protections related to appealing a denial of
coverage or payment. The Medicaid managed care appeals regulations
are set forth in Subpart F of Part 438 of Title 42 of the CFR.
Rules on the content of the written denial notice can be found at
42 CFR 438.404. This notice combines the existing Notice of Denial
of Medicare Coverage with the Notice of Denial of Payment and
includes optional language to be used in cases where a Medicare
health plan enrollee also receives full Medicaid benefits that are
being managed by the Medicare health plan.
Statute at
Large: 18
Stat. 1852 Name of Statute: null
US Code: 42
USC 1395w-22 Name of Law: Implementation of Medicare Advantage
Program
US Code: 42
USC 1396u-2 Name of Law: Provisions Relating to Managed
Care
Statute at Large: 19
Stat. 1932 Name of Statute: null
Based on data reported to CMS
by Medicare health plans, there were 33,574,293 adverse and
partially favorable decisions issued in 2014. CMS acknowledges that
these burden estimates are significantly higher than the estimates
contained in the previous package for CMS-10003 in 2013. The
26,613,883 response increase in the number of reported adverse and
partially favorable decisions (from 6,960,410 based on 2011 data to
33,574,293 based on 2014 data) is primarily due to changes in
reporting requirements for plans.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form CMS-10003 Notice of Denial of Medical Coverage (or Payment)
Justification for Nonsubstantive Change.docx
Notice of Denial of Medical Coverage (or Payment)