60 Day Public Comment Response

CMS Response to Public Comments Received for CMS-10003

The Centers for Medicare and Medicaid Services (CMS) received comments from
Ancorat Consulting, Blue Cross Blue Shield Association, Prime Therapeutics, and one
anonymous commenter related to CMS-10164. This is the reconciliation of the
comments.

Comment:
CMS received a comment from Ancorat Consulting suggesting that language stating “If
you’re asking for an appeal and missed the deadline, you may include the reason for
being late”, be more specific if CMS’ intent is to inform enrollees they may ask for a
good cause extension and may include their reason for being late.
Response:
CMS agrees more specific language would be beneficial to the enrollee and has
revised the sentence to state “If you’re asking for an appeal and missed the deadline,
you may request an extension and should include the reason for being late".
Comment:
CMS received a comment from Ancorat Consulting recommending CMS modify a
reference to “drugs” in the crosswalk on page 7 to specify “Part B or Medicaid drugs”,
citing it does not reflect the change made in the form instructions in “Section Titled:
Your request was denied”.
Response:
CMS has corrected the crosswalk to reflect the change in the form instructions.
Comment:
CMS received comments from Blue Cross Blue Shield Association. Several of the
comments were inquiry in nature rather than suggested changes to the actual
documentation.

Response:
CMS appreciates the suggestions, concerns and questions expressed by this
commenter. Each bulleted item will be addressed individually.

Comment:
1) “On page 1, the denial letter has been changed to allow an option with additional
descriptions of actions performed, including a partial approval. Does a separate
approval letter also have to be sent (if applicable) or can that approval language be
added as free text?”
Response:
Thank you for your comment. This question is outside of the scope of this PRA
submission. Please submit any policy related questions to the Medicare Part C
appeals and grievances resource mailbox, [email protected].

Comment:
2) “On Page 1 heading, the instructions say that the HIC number cannot be used. Is the
UMI still acceptable or should the MBI be used?”
Response:
On Page 1 of the instructions, under “Heading” language that stated “The HIC
number cannot be used” was removed. Plans should insert the enrollee’s plan
identification number, as indicated on the instructions.

Comment:
3) “On Page 1, section on your appeals was denied, is there a specific date format that
is required?”
Response:
Plans may use any date format that includes the month, date, and year. For
example, both “01/01/2019” and “January 1, 2019” are acceptable date formats.

Comment:
4) “On page 2, the change allows the member to indicate the reason why they are late
with an appeal. Is this a change to the member’s rights? Who decides whether the
reason for the late appeal would be considered “good cause”?”

Response:
CMS has not changed policy related to member rights. As indicated in the
crosswalk, the language was added to inform enrollees they may request an
extension from the plan if they miss the deadline for filing an appeal and should
include their reason for being late.

Comment:
CMS received a comment from Blue Cross Blue Shield Association stating they believe
language on page 3 that reads, “If you ask for an appeal, we will send you another letter
with a decision to tell you if we approve or deny your request”, may be confusing to a
member and they suggest CMS replace with “If you ask for an appeal, we will send you a
letter once a decision is made”.
Response:
CMS thanks the commenter for identifying potential opportunities to reduce
enrollee confusion. Because plans are not required to send notification to an
enrollee if their case is forwarded to the Independent Review Entity, CMS has
revised this sentence to more accurately reflect what enrollees can expect following
an appeal. Please see revised form and crosswalk for specific changes.
Comment:
CMS received a comment from Blue Cross Blue Shield Association suggesting CMS
insert curly brackets (i.e. { }) around “phone” as a part of the standard appeal information
on page 3, step 2 of the form.
Response:
CMS has accepted this suggestion and thanks the commenter for their feedback.
Comment:
CMS received a comment from Prime Therapeutics advising CMS that the 24-hour fast
appeal timeframes for Part B drugs provided in CMS-10003 do not align with 72-hour
expedited timeframes for Medicare Part B drugs in Final Rule 84 FR 23832 (42 CFR
422.590(e)), and requests CMS correct or provide clarification on the timeframes.

Response:
CMS thanks you for your comment and has corrected the Part B drug timeframes
in CMS-10003.

Comment:
CMS received a comment from Prime Therapeutics suggesting Medicaid language under
“There are 2 kinds of appeals with {health plan name} Standard Appeal” which states
“[Insert timeframe for standard internal plan Medicaid appeals, if different]” also be
included in the “Fast Appeals” section for plans to populate variable Medicaid
timeframes for fast appeals.
Response:
CMS agrees with the commenter’s recommendation and has also included language
regarding expedited timeframes for Medicaid appeals in the “Fast Appeals” section
of the form.

Comment:
CMS received a comment from Prime Therapeutics seeking clarification on whether the
IDN is the appropriate notice when there is a chance a drug may be covered under the
Medicare Part D benefits, stating there are situations when a drug/item may be covered
under Medicare Part D benefit.
Response:
If a Medicare Advantage Prescription Drug (MA-PD) plan receives a coverage
determination request, they must take necessary steps to ensure the request is
processed and resolved for both Part B and Part D. CMS recently revised the Part
D denial notice (CMS-10146) to ensure if an MA-PD denied a drug under Part D,
they take the necessary steps to make sure the drug is processed under Part B. If it
is covered under Part B and the plan denies, an IDN must be issued.

Comment:
CMS received a comment from an anonymous commenter suggesting CMS allow plans
to modify the term “medical service/item or Part B drug or Medicaid drug” for denials of
dental services, stating “medical service/item” does not work well for most supplemental
dental services.
Response:
CMS thanks the commenter for the suggestion, however, CMS does not believe
using the term “medical service” has adverse impact for supplemental dental
services as the free-text fields populated by plans provides a more specific
description of what is being denied. CMS will keep the term “medical service/item
or Part B drug or Medicaid drug”.