60 Day Crosswalk

Currently
approved
version

New version with change

Type of
Change

Sub sections titled For an
Expedited Appeal" and "For a
Standard Appeal" are reworded.
Sections now read as follows. "For
an Expedited (Fast) Appeal: You,
your prescriber, or your
representative can file an appeal by
telephone, by fax, through the
plan’s website, or by mail. A verbal
request by telephone is the fastest
way to file an expedited (fast)
request. Phone:, TTY:
For a Standard Appeal: [Plan that
accepts verbal standard requests:]
{You, your prescriber, or your
representative can file an appeal by
telephone, by fax, through the
plan’s website, or by sending a
letter to the mailing address listed
NoticeSection titled below.}
[Plan that does not accept verbal
"How Do I
standard requests:] {You, your
Request an
Appeal?" until prescriber, or your representative
section titled can file an appeal by TTY, fax,
through the plan’s website, or by
"What
sending a letter to the mailing
Happens
Nonsubstantive
Next?"
address listed below.}

Reason for Change

Change
Burden from 60Change Day

Modified to increase
accessibility of plan
websites allowing
electronic access for
beneficiaries. Modified
to reduce confusion
with which type of
appeal requires which
type of correspondance.
Changes correspond
with §423.128(b)(7)(ii)
and §423.136.
No.

Yes.

Text is modified to match the
information required in the notice.
Subsections explaining what to
include for expedited and standard
appeals are consolidated to
uniformly present of different ways
to appeal. Sections allow plans to
provide information based on
whether verbal requests are
accepted for standard appeals.
Section now reads as follows:
"Under the section titled 'How Do I
Request an Appeal?' the subsection
titled 'For a Standard Appeal' gives
two options. If the plan accepts
verbal requests for standard
appeals, the plan must keep the
information after the brackets that
states 'For plans that accept verbal
standard requests'. If the plan does
not accept verbal standard
requests, the plan must keep the
section after the brackets that
states 'For plans that do not accept
verbal standard requests'. Plans are
Instructions- required to enter the telephone
Section titled number if plan accepts verbal
"Section
requests, TTY number, fax number,
Titled: How Do plan website and physical address
I Request an that the enrollee, prescriber, or the Nonenrollee’s representative can use substantive
Appeal?"

Changed to match the
information
modification in the
notice.

No.

Yes.

In the last sentence of this
instruction, the word "appeal" is
removed from the paragraph, as
plans are required to include their
appeal website above under the
section titled "How Do I Request an
Appeal?". Instead of the appeal
website, plans should include their Nongeneral website here.
substantive

Changed to match the
information
modification in the
notice.

No.

Yes.

InstructionsSection titled
"Section
Titled: Get
Help & More
Information"

InstructionsIn section
referencing
"Additional
Instructions
for Drugs not
covered under
Part D when
the plan has
determined
that the drug
is or ma be
covered under
Medicare Part
A or Part B:",
after
paragraph
beginning with
"MA-PD"

The paragraph beginning with MAPD" has been rewritten to include
instructions for Part B step therapy
requirements. The paragraph now
reads as follows: "Where the plan
processes a Part D coverage
determination but determines that
the requested drug is covered
under Part A or Part B, insert the
following additional text: 'This
request was denied under your
Medicare Part D benefit; however,
coverage/payment for the
requested drug(s) has been
approved under Medicare Part A/B
{include an explanation of the
conditions of approval in a
readable and understandable
format}. If you think Medicare Part
D should cover this drug for you,
you may appeal.' If the plan
determines that the requested
drug is typically covered under Part
B and instead processes a Part C
organization determination, the
plan must send the Integrated
Denial Notice (CMS-10003) if
coverage is denied under Part B
Substantive
(e.g., Part B drug step therapy

Added to reflect new
2019 regulations
concerning Part B step
therapy §422.136(a).

No.

No.

The paragraph beginning with "The
Part D" has been edited for clarity
regarding the appropriate language
version of the notice. The
paragraph now reads "The Part D
Instructions- Denial Notice is available in English
and Spanish. Part D plan sponsors
The second
should choose the version of the
paragraph
beginning with notice that will be readable and
Non"The Part D.." understandable to the beneficiary." substantive

This paragraph change is
to streamline the
instruction on using the
appropriate version of
the notice (English or
Spanish). This edit aims
to focus on
readability/understanda
bility for beneficiaries. No

Yes.

The sentence in the beginning that
notifies beneficiaries if their right
to appeal the denial now reads
"…you can call one of the numbers
listed on the third page under…"
instead of "…you can call one of
the numbers listed on the last page Nonunder…"
substantive

This change reflects that
the phone numbers
referenced in the notice
are on the third page,
not the last page.
No

Yes.

NoticeHeader titled
"Important"

Notice- In the
section titled
"Important
Information
about your
Appeal
Rights", the
subsection
titled
"Standard (7
days)"

The sentence saying "If your appeal
is for payment of a drug you’ve
already received, we’ll give you a
written decision within 14 days."
Nonwas added back to the notice.
substantive

Request from public
comments.

No

Yes.