Crosswalk

EXHIBIT A
Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP
CHANGE CROSSWALK

NOTICE
On Page 1 under
section:
Why did we deny your
request?

CHANGES TO
NOTICE

EXPLANATION

Changed all terms that
stated “Part B or
Medicaid drug” to “Part
B drug or Medicaid
drug”.

This change was made
to better clarify plans
should enter the term
“Part B drug” and not
“Part B”, when
applicable.

Fast Appeal – We’ll give
you a decision on a fast
appeal within 72 hours.
[Insert timeframe for
expedited internal plan
Medicaid appeals, if
different]

Corrected error for fast
appeal timeframes and
added language for plans
to insert the fast appeal
timeframe for a Medicaid
appeal, if different than 72
hours.

On Page 2 under section:
How to ask for an appeal
with {health plan name}
Step 1:

On Page 3 under section:
“What happens next?”
On page 2, within “Fast
Appeal” paragraph under
section “There are 2
kinds of appeals with
{health plan name}”.
Fast Appeal - We’ll give
you a decision on a fast
appeal within {insert
appropriate timeframe for
medical service/item or
Part B or Medicaid drug:
72 hours, 24 hours}
On page 2, under
section “How to ask for
an appeal with {health
plan name}”:

If you’re asking for an
appeal and missed the
deadline, you may
request an extension and

Added language to specify
an enrollee may ask for a
good cause extension.

Page 1 of 4

NOTICE
If you’re asking for an
appeal and missed the
deadline, you may include
your reason for being late.
On page 3 under section
“How to ask for an
appeal with {health plan
name}”:
For a Standard Appeal:
Mailing Address: {In
Person Delivery
Address:}
{Phone:}
{TTY Users Call:}
Fax:

On page 3, under section
“What happens next?”
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. If we
continue to deny your
request for {payment of} a
{medical service/item or
Part B or Medicaid drug},
we’ll send you a written
decision and automatically
send your case to an
independent reviewer.

CHANGES TO
NOTICE

EXPLANATION

should include your
reason for being late.

“How to ask for an
Restored curly brackets
appeal with {health plan around “Phone” under
name}”:
standard appeals. Plans
are not required to accept
For a Standard Appeal: verbal requests for
appeals and curly
Mailing Address: {In
brackets provide plans the
Person Delivery
option to add a phone
Address:}
number.
{Phone:}
{TTY Users Call:}
Fax:

“What happens next?”
‘If you ask for an appeal
and we continue to deny
your request for {payment
of} a {medical service/item
or Part B drug or Medicaid
drug, we’ll automatically
send your case to an
independent reviewer.

Removed language
regarding enrollees
receiving a decision letter
because plans are not
required to send
notification to an enrollee
if a denial is upheld and
their case is forwarded to
the IRE.

Page 2 of 4

INSTRUCTIONS
On all pages
throughout various
sections of the
instructions, there is
use of the term “Part
B or Medicaid drug”.
On page 2, under
Section Titled: Why
did we deny your
request?

CHANGES TO
INSTRUCTIONS
Changed “Part B or
Medicaid drug” to “Part
B drug or Medicaid
drug”

Section Titled: Why
did we deny your
request?

Additional instructions
for Medicare
Plans that provide both
Advantage
Medicare and Medicaid
Prescription Drug
benefits (e.g., integrated
Dual Special Needs Plans) plans (MA-PDs) and
Medicare Part B drugs
should determine if the
that may be covered
request for payment or
under Part D:
coverage concerns a
service or item covered
under the plan’s Medicare Where an MA-PD has
determined that the
or Medicaid benefits.
requested drug is
covered under Part D,
insert the following
additional text:

EXPLANATION
This change was made to
better clarify plans should
enter the term “Part B
drug” and not “Part B”,
when applicable.
Added instructions for MAPDs to include an
explanation in the denial
rationale for enrollees if a
Part B drug may be
covered under Part D.

Also added a heading to
clearly distinguish where
instructions are specific to
plans that provide both
Medicare and Medicaid
benefits.

“This request was
denied under your
Medicare Part B benefit;
however,
coverage/payment for
the requested drug(s)
has been approved
under Medicare Part D
{include an explanation
of the conditions of
approval in a readable
and understandable
format}. If you think
Medicare Part B should
cover this drug for you,
you may appeal.”

Page 3 of 4

INSTRUCTIONS

CHANGES TO
INSTRUCTIONS

EXPLANATION

Additional instructions
for plans that provide
both Medicare and
Medicaid benefits:
Plans that provide
both Medicare and
Medicaid benefits¹
(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.

Page 4 of 4