Crosswalk

EXHIBIT A
Coverage Decision Letter CMS-10716
CHANGE CROSSWALK
Form

Change to Form

Explanation

Throughout form

Changed all instances of to

Changed for consistency
with the form instructions.

Throughout form

Changed font from Times New
Roman 12 to Arial 11

Changed to more closely
align with other CMS
model notices developed
for Medicare-Medicaid
Plans under the Financial
Alignment Initiative
capitated model
demonstrations.

Page 1 in 1st paragraph.

Updated language:

Original language:

is a health plan that
contracts with Medicare and
Medicaid [Replace with statespecific term for Medicaid, if
applicable] to provide coverage for
both programs. Our plan
coordinates your Medicare and
Medicaid [Replace with statespecific term for Medicaid, if
applicable] services and your
doctors, hospitals, pharmacies,
and other health care providers.

Edited to ensure the
language was appropriate
for both FIDE SNPs and
HIDE SNPs.

is called “our
plan” or “we” in this letter.
Our plan is your health
insurance company. We
combine:

•

your Medicare and
Medicaid [Insert statespecific term for
Medicaid, if applicable]
services.

•

your doctors, hospitals,
pharmacies, and other
health care providers
into one coordinated
system.

Page 1 in 2nd paragraph.

Added language to 2nd paragraph:
Our plan [Insert if

Added “partially denied” as
an option to correct an
omission.

Form

Change to Form

Explanation

applicable: payment for] the
listed below:
Page 1 in 2nd paragraph
plan instruction.

Added language to 2nd paragraph
plan instruction:
[Insert description of service or
item being denied, partially
denied, reduced, stopped, or
suspended, and include doctor or
provider’s name if a particular
doctor or provider requested the
service or item.]

Page 1 in third paragraph

Edited 3rd paragraph plan
instructions:
Our plan made this decision
because [Provide a specific denial
reason and a concise explanation
of why the service/item was
denied and include state or federal
law and/or Evidence of
Coverage/Member or Enrollee
Handbook provisions to support
the decision. Write rationale in
plain language – see instructions
for more information].

Page 1 under section titled
You have the right to
appeal our decision

Added second paragraph using
language previously under the
section titled “How to appeal”:
You can also call
(TTY: ) and ask us
for a free copy of the information
we used to make our decision.
This may include health records,
guidelines, and other documents.
You should show this information
to your to help you decide if you
should appeal.
Page 2 under section titled
There are two kinds of
appeals

Changed all instances of the plan
instruction throughout this section
to:

Original plan instruction:

[for a Part B drug, insert: 7
calendar days or for any other
service or item, insert: 30
calendar days or a shorter
timeframe if required by the state]

<30 calendar days or for a
Part B drug 7 calendar
days>
Page 2 under section titled
“There are two kinds of
appeals”

Page 2 under section titled
“There are two kinds of
appeals”

Changed 1st sentence under #2 of
this section to:
If you ask for a fast appeal, our
plan will give you a decision within
[72 hours or a shorter timeframe if
required by the state] after we get
your appeal.”
Added sentence to the end of the
first paragraph under #2 of this
section:

Changed to clarify the
different amounts of days
plans must add for Part B
drug and/or a state-specific
timeline.

Changed to provide
flexibility for a plan to insert
a state-specific timeline
when required under the
state Medicaid agency
contract.

Added language to note an
exception to the ability to
receive a fast appeal.

“Note: You can’t get a fast appeal
if our plan denied payment for a
service you already got.”
Page 2 under section titled
“There are two kinds of
appeals”

Reformatted the original last
paragraph of this section to be the
2nd paragraph of #2 of this section.
Moved language from the original
last sentence of #1 to be the new
last paragraph of this section

Page 2 under section titled
“How to appeal”

Added language to first sentence
of this section:
You, someone you have named in
writing as your representative to
act on your behalf (such as a

Changed language to
clarify that a plan may
delay a decision for both a
standard and fast appeal.

Added language to note
the member must name a
representative in writing.

Form

Change to Form

Explanation

relative, friend, or lawyer), or your

can appeal.
Page 2 under section titled
“How to appeal”

Added language to 3rd sentence
of this section:
• Mail: Mail it to

Edited to clarify plan
instruction regarding
mailing address.

Page 3 under section titled
“How to appeal”

Deleted second to last paragraph
of this section.

Moved information in this
paragraph to improve
readability of the form.

Page 3 under section titled
“How to appeal”

Added language to the plan
instruction in the last paragraph’s
second sentence:

Added flexibility for an
alternate name for
Evidence of Coverage that
may be used by some
plans as well as for
referencing the specific
chapter and/or section that
includes the additional
information.

You can also find more
information in our plan’s [insert
Evidence of Coverage, Member or
Enrollee Handbook, or other term
plan uses], [plans may insert
chapter and/or section reference,
as applicable]. An up-to-date copy
of the [insert Evidence of
Coverage, Member or Enrollee
Handbook, or other term plan
uses] is always available on our
website at or by
calling our plan.
Page 3 under section titled
“How to keep getting your
during
your appeal”

Added language to plan
instruction in the 1st bullet:
[Insert continuation of benefits
request filing date in month,
date, year format. Date will be
the later of the following: (1) 10
calendar days from date of
letter (or later than 10 calendar
days, if required by the state),

Changed to provide
flexibility for a plan to insert
a state-specific timeline
when required under the
state Medicaid agency
contract.

Form

Change to Form

Explanation

or (2) date the decision takes
effect]
Under section titled “How
to keep getting your
during
your appeal”

Added 4th bullet:
•

Page 4 under section titled
“What happens next”

Changed last sentence of this
section to:

If your is filing the appeal
for you and you want your
to continue,
then your must include
your written consent.

If our plan still denies [Insert if
applicable: payment for] the
listed on the first
page of this Coverage Decision
Letter, the Appeal Decision Letter
will tell you what happens next,
such as information about a
Medicare Level 2 appeal or how to
ask for a Fair
Hearing.
Page 4 under section titled
“What to do if you need
help with your appeal”

Changed 1st sentence in 1st
paragraph to:
You must first name them in
writing as your “representative” by
following the steps below.

Changed to note the need
for consent when a
provider is requesting a
continuation of benefits.

Added a reference to Level
2 appeals and processes
for getting a Fair Hearing
from the state.

Added language to note
the member must name a
representative in writing.

Form

Change to Form
Edited the 1st bullet of this section:

Explanation

Page 4 under section titled
“What to do if you need
help with your appeal”

•

Page 5 under section titled
“Get help and more
information”

Corrected Medicare Rights Center
phone number and added a
website under 6th bullet

Corrected an error and
omission.

Page 5 under section titled
“Get help and more
information”

Corrected “Elder Care” to
“Eldercare” and updated the web
address under 7th bullet

Corrected an error.

Spanish Translation

Included a Spanish translation
version of the coverage decision
letter in this 30 day notice

Translated the revised
coverage decision letter for
Spanish speaking
beneficiaries

Spanish Translation Page 5
under “Obtenga ayuda y
más información”

Added additional instruction to
“Centro de Derechos de
Medicare” bullet not included in
the English version

Included an instruction on
how to directly access
Spanish assistance when
calling the Medicare Rights
Center

Instruction

Call our plan at (TTY: ) to learn how to
name that person as your
representative. Or, you can
visit Medicare.gov/claimsappeals/file-an-appeal/cansomeone-file-an-appeal-forme. [Plans may replace with a
plan-specific web address that
explains how members can
appoint a representative.]

Change to Instruction

Added flexibility for plans
to include a plan-specific
web address to the
personal representative
form.

Explanation

Throughout instructions

Changed “form” to “letter”

Corrected terminology.

Throughout instructions

Added Medicare before Part B
drug

Added to improve clarity.

Instruction

Change to Instruction

Explanation

Throughout instructions

Changed all instances of to

Corrected for consistency
throughout form and
instructions.

Page 1 under section titled

Added the last sentence to the
first paragraph of this section:
“This letter must be used in place
of the Notice of Denial of Medical
Coverage (or Payment) (NDMCP)
form (CMS10003).”

Added clarification on use
of the form.

Added the second paragraph to
this section.

Added clarification on the
use of the form.

Inserted as 1st bullet language
previously under section “When
should the plan use this
letter?”:

Changed to improve the
organization and
readability of the form
instructions.

“When should the plan
use this letter?”

Page 1 under section titled
“When should the plan
use this letter?”
Page 1 under section titled
“Formatting and language
requirements”

• The letter contains text in pointed
brackets < > when a particular
piece of data must be inserted
into the document and the data
are either:
1. Based on the specific situation
involved – for example, the
appropriate term to be inserted
depends on the situation, or
2. Specific to the individual letter –
for example, an effective date or
deadline date.
Page 1 under section titled
“Formatting and language
requirements”

Inserted as 2nd bullet language
previously under section “When
should the plan use this
letter?”:

Changed to improve the
organization of and explain
the plan instructions in the
form.

Instruction

Change to Instruction

Explanation

• Instructions to plans appear in
blue italicized text and brackets [ ]
and are only for plan use.
And added to the 2nd bullet the
following sentence:
Plans must ensure that no blue
text remains in the Coverage
Decision Letters that plans send to
members.
Page 2 under section titled

Inserted the 6th bullet:

“Formatting and language • When the letter gives the plan
requirements”
specific choices about word
usage (e.g.,
),
the plan should choose the term
that fits the circumstances and
use it consistently throughout the
notice.
Page 2 under section titled

Add this section and language:

“Required timeframes in
this letter”

Plans operating in states that have
established shorter timelines for a
plan to make a decision on an
appeal must replace any relevant
timeframes with those set by the
state. These timeframes must be
documented in the plan’s state
Medicaid agency contract as
provided under 42 CFR
422.629(c). This letter includes
instructions for timeframes where
such replacements are possible.

Page 2 under section titled

Edited the 4th bullet:

“Heading instructions”

• Service/item this letter is
about: Insert, in plain language,
the name and/or brief
description descriptor of the

Changed to explain the
plan instructions in the
form.

Changed to clarify when
plans should change
timeframes listed in the
form.

Edited to improve
readability.

Instruction

Change to Instruction

Explanation

service or item that was
requested and for which
authorization and/or payment is
being denied
Page 3 under section titled

Edited the 5th bullet:

“Heading instructions”

• [Insert Additional Field(s) as
needed, when plan is required
by state to include specific
information in the letter]: The
plan is permitted to insert
additional fields of information in
the header section of the letter if
needed, consistent with
applicable state requirements,
such as the name of the
provider making the request or
the member’s Medicaid number.
If the plan operates in a state
that requires contracted plans to
include additional fields in this
table, add those fields.

Page 3 under section titled

Edited the 2nd bullet:

“First paragraph of letter”

• In the first sentence and first
bullet point of this paragraph,
insert replace “Medicaid” with
the state-specific term for
Medicaid, if applicable.

Page 3 under section titled

Added partially denied as a plan
choice in the first paragraph and
first bullet.

Edited to conform with
changes to the form.

Page 3 under section titled

Edited 1st paragraph:

“Third paragraph of letter”

In the sentence that begins, “Our
plan made this decision because,”
the plan should provide a specific
denial reason and detailed a

Edited to improve
readability and conform to
plan instruction language
in the form.

“Second paragraph of
letter”

Changed to clarify when
plans should insert
additional information.

Edited to conform with
changes to the form.

Instruction

Change to Instruction

Explanation

concise explanation of why the
service/item was denied, including
a description of the applicable
Medicare (and include state or
Medicaid) coverage rule federal
law and/or applicable plan policy
(for example, Evidence of
Coverage provision) upon which
the action was based/Member or
Enrollee Handbook provisions to
support the decision.
Page 4 under section titled
“Third paragraph of letter”

Inserted the following sentence to
the 2nd bullet:
If the plan considered both
Medicare and Medicaid coverage
rules in making its decision, the
description should include both
sets of rules.

Page 4 under section titled
“Third paragraph of letter”

Inserted the following sentence
into the 3rd bullet:
If the plan considered both
Medicare and Medicaid coverage
rules, the explanation should
describe how both coverage rules
were applied in this case.

Page 4 under section titled

Inserted the second paragraph:

“Section titled: You have
the right to appeal our
decision”

In the second paragraph, the plan
should insert the most appropriate
plan phone and TTY numbers for
appeal requests. The plan may
insert the toll-free Member
Services phone number and tollfree TTY number if the plan
doesn’t have a specific phone
number for appeal requests.

Added language based on
comments regarding the
importance of information
on Medicare and Medicaid
coverage rules for
beneficiaries when making
an appeal.
Added language based on
comments regarding the
importance of information
on Medicare and Medicaid
coverage rules for
beneficiaries when making
an appeal.
Added language to clarify
that plans should insert the
most appropriate phone
number for appeal
requests.

Instruction
Page 5 under section titled
“Section titled: There are
two kinds of appeals”

Change to Instruction
Inserted the following sentence
into the 1st paragraph:
Plans operating in states with
shorter timelines to make a
decision on an appeal must
replace any relevant timeframes
with those established by the state
and documented in the state
Medicaid agency contract.

Page 5 under section titled

Edited 1st paragraph:

“Section titled: How to
appeal”

The plan should insert its toll-free
the most appropriate plan phone
and TTY numbers, fax number,
mailing address, and, if
appropriate, the in-person delivery
address that members may use to
file an appeal. The plan may insert
the toll-free Member Services
phone number and toll-free TTY
number if the plan doesn’t have a
specific phone number for appeal
requests.

Page 5 under section titled

Deleted paragraph:

“Section titled: How to
appeal”

In the paragraph that starts “On
the first page of this Coverage
Decision Letter,” the plan should
insert the appropriate term to
describe the action taken in this
letter. If the denial involves a
payment request, insert the
“payment for…” text.

Page 5 under section titled

Edited 3rd paragraph:

“Section titled: How to
appeal”

In the paragraph that starts, “To
get more information on how to
appeal”, the plan must insert the
plan’s toll-free Member Services

Explanation
Changed to clarify when
plans should change
timeframes listed in the
form.

Added language to clarify
that plans should insert the
most appropriate phone
number for appeal
requests.

Edited to conform with
changes to the form.

Added flexibility to allow an
alternate name for the
Evidence of Coverage that
may be used by some
plans as well as a
reference to the specific

Instruction

Page 6 under section titled
“Section titled: How to
keep getting your
during
your appeal”

Page 6 under section titled
“Section titled: What
happens next”

Page 6 under section titled
“Section titled: What to do
if you need help with your
appeal”

Change to Instruction

Explanation

phone number in the
field and toll-free TTY number in
the field. In the
second sentence, the plan may
also include additional chapter
and/or section reference
information, as applicable. The
plan should also insert the
appeals chapter and section
number of the plan’s Evidence of
Coverage (EOC) in the field
and the website where members
can access the most current
version of the plan’s EOC
Evidence of Coverage/Member or
Enrollee Handbook document in
the field.

chapter and/or section that
includes the additional
information.

Inserted language into the 1st
bullet:

Changed to provide
flexibility for a plan to insert
a state-specific timeframe
when required under the
state Medicaid agency
contract.

• 10 calendar days from the date
of the letter (or later than 10
calendar days, if required by the
state)
Inserted the following sentence at
the end of the 1st paragraph:
The plan should insert the state
name as indicated in the fields
with pointed brackets.
Modified first paragraph in this
section:
In the field indicated by pointed
brackets first bullet in this section,
the plan should insert the toll-free
most appropriate plan phone and
TTY numbers in the fields with

Added instruction based
on additional language
added to the form
regarding a Fair Hearing
from the state.
Changed to clarify
information plans can
provide to assist members
in how to name an
authorized representative.

Instruction

Change to Instruction

Explanation

pointed brackets to be used if the
member needs information on
how to name an authorized
representative for the purposes of
the appeal. The plan should also
may insert, in the appropriate
fields, the address and fax toll-free
Member Services phone number
that may be used to submit
authorized and toll-free TTY
number if the plan doesn’t have a
specific phone number for
representative requests. The plan
may also replace the
Medicare.gov web address with a
plan-specific web address that
explains how members can
appoint a representative.
Page 6 under section titled
“Section titled: What to do
if you need help with your
appeal”

Inserted a 2nd paragraph to this
section reading:
In the third bullet in this section,
the plan should insert, in the
appropriate fields, the mailing
address and fax number that may
be used to submit authorized
representative requests.

Added instruction based
on additional language
added to the form.