30 day Crosswalk

EXHIBIT A
Coverage Decision Letter CMS-10716
CHANGE CROSSWALK 30 DAY NOTICE TO FINAL VERSION
Form-English

Change to Form

Explanation

Throughout form

Made corrections to plan
instruction formatting.

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, heading.

Added language to plan
instruction: [Insert additional
field(s) as needed or when
required by state, such as provider
or Member Medicaid ID]

Edited to clarify a plan has
the flexibility to insert
additional fields as needed
and not only when required
by the state.

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

Added plan instruction to last
paragraph in this section: [Delete
if the letter is for a denial of a Part
B drug:

Changed to clarify that a
plan may remove language
that does not apply to a
Part B drug.

Page 3, section titled “How
to appeal.”

Changed language in the following
sentence:

Edited to improve
readability.

If you call, we’ll send you a notice
letter that says what you told us
on the phone.
Page 3, section titled “How
to keep getting your
during
your appeal.”

Added language to the first bullet
in this section:
You must appeal and ask our
plan to continue getting your

Edited to clarify that a
beneficiary must appeal to
continue benefits during
the appeal process.

Form-English

Change to Form

Page 4, section titled “How
to keep getting your
during
your appeal.”

Added the following language to
plan instruction in the first bullet in
this section:

Page 4, section titled “How
to keep getting your
during
your appeal.”

Changed language in the fourth
bullet in this section:

Explanation
Changed to correct an
omitted instruction.

Insert date in bold text
Edited to improve
readability.

If your is filing the appeal for
you and you want to keep getting
your to continue,

Page 4, section titled “What
happens next.”

Added plan instruction: [Insert if
appropriate: (also called a )].

Changed to provide
flexibility for a plan to insert
a state-specific term when
applicable.

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

Changed language and formatting
of the third bullet in this section.

Changed to improve
readability.

Mail or fax the signed statement to
us at:
or fax it to us at

Page 5, end of the letter.

Added plan instruction at the end
of the letter:
You can get this document for free
in [Insert, as appropriate: or] other
formats, such as large print,
braille, or audio. Call .

Changed to account for the
removal of the plan
instruction noted below.

Form-English
Page 5, plan instruction at
end of document.

Form-Spanish

Change to Form
Deleted the following plan
instruction: [Plans are subject to
the notice requirements under
Section 1557 of the Affordable
Care Act. For more information,
visit https://www.hhs.gov/civilrights/for-individuals/section1557.]

Change to Form

Explanation
Removed this instruction to
conform to other CMS
notices, such as CMS10003.

Explanation

Throughout form

Made corrections to plan
instruction formatting.

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, heading.

Added language to plan
instruction: [Insert additional
field(s) as needed or when
required by state, such as provider
or Member Medicaid ID]

Edited to clarify a plan has
the flexibility to insert
additional fields as needed
and not only when required
by the state.

Page 2, section titled “Hay
dos clases de apelaciones.”

Added plan instruction to last
paragraph in this section: [Delete
if the letter is for a denial of a Part
B drug:

Changed to clarify that a
plan may remove language
that does not apply to a
Part B drug.

Page 3, section titled
“Cómo apelar.”

Changed language in the following
sentence:

Edited to improve
readability.

Si llama, le enviaremos una
notificación carta que incluye lo
que usted nos dijo por teléfono.

Form-Spanish

Change to Form

Page 4, section titled
“Cómo seguir recibiendo su

durante su apelación.”

Added language to the first bullet
in this section:

Page 4, section titled
“Cómo seguir recibiendo su

durante su apelación.”

Added the following language to
plan instruction in the first bullet in
this section:

Page 4, section titled
“Cómo seguir recibiendo su

durante su apelación.”

Changed language in the fourth
bullet in this section:

Usted debe tiene que apelar y
pedir a nuestro plan seguir
recibiendo su

Explanation
Edited to clarify that a
beneficiary must appeal to
continue benefits during
the appeal process.

Changed to correct an
omitted instruction.

Insert date in bold text
Edited to improve
readability.

Si su está
presentando la apelación en su
nombre y usted quiere que
continuar recibiendo su continúe,

Page 4, section titled “Qué
sucede después.”

Added plan instruction: [Insert if
appropriate: (lo que también
conocemos cómo )].

Changed to provide
flexibility for a plan to insert
a state-specific term when
applicable.

Page 5, section titled “Qué
debe hacer si necesita
ayuda con su apelación.”

Changed language and formatting
of the third bullet in this section.

Changed to improve
readability.

Envíenos, por correo o fax, la
declaración firmada por correo a:
o por fax al

Form-Spanish
Page 5, end of the letter.

Change to Form

Explanation

Added language and a plan
instruction at the end of the letter:

Changed to account for the
removal of the plan
instruction noted below.

Usted puede obtener este
documento de forma gratuita en
inglés [Insert, as appropriate:
] u
otros formatos, como en letra
grande, braille, o audio. Llame al
. La llamada es
gratuita.

Page 5, plan instruction at
end of document.

Instructions

Deleted the following plan
instruction: [Plans are subject to
the notice requirements under
Section 1557 of the Affordable
Care Act. For more information,
visit https://www.hhs.gov/civilrights/for-individuals/section1557.]

Removed this instruction to
conform to other CMS
notices, such as CMS10003.

Change to Instructions

Explanation

Throughout instructions.

Added phrase “blue instruction to
the plan” where necessary and
instead of “instructional brackets”.

Changed to clearly identify
where plans should edit
the document.

Page 1, section titled
“When should the plan use
this letter?”

Edited the reference to a
document in the first paragraph of
this section.

Changed to match the title
of the document.

the Notice of Denial of Medical
Coverage (or Payment) (NDMCP)
form (CMS-10003-NDMCP)

Instructions
Page 1, section titled
“When should the plan use
this letter?”

Change to Instructions
Edited the reference to a
document in the second
paragraph of this section.

Explanation
Changed to match the title
of the document.

Notice of Denial of Medicare Part
D Prescription Drug Coverage, for
Part D denials
Page 1, section titled
“Formatting and language
requirements.”

Edited the following language in
the first bullet of this section.

Page 1, section titled
“Formatting and language
requirements.”

Edited the following language in
the second bullet of this section.

Page 2, section titled
“Heading instructions.”

Changed to improve
readability.

The letter contains text in pointed
brackets < > when a piece of data
must be inserted the plan must
insert particular information into
the document, and the data it is
either:

Plans must ensure that no blue
italicized text remains and that
blue non-italicized text is changed
to black text in the Coverage
Decision Letters that plans send to
members.
Edited the following language in
the second bullet of this section.

Changed to clarify how
plans should customize the
form.

Corrected language to
match form.

Member name [Insert Member
name]:
Page 3, section titled
“Heading instructions.”

Added language to plan
instruction in the fourth bullet of
this section.
[Insert additional field(s) as
needed or when plan is required
by state to include specific
information in the letter, such as
provider or Member Medicaid ID]

Changed to correspond
with a change to the form.

Instructions
Page 3, section titled
“Heading instructions.”

Change to Instructions
Edited the following language in
the fifth bullet of this section:

Explanation
Corrected term.

If the plan operates in a state that
requires contracted plans to
include additional fields in this
table heading, add those fields.

Page 3, section titled: “First
paragraph of letter.”

Edited the first sentence and
added a second sentence to the
second bullet in this section:
In the first and second and third
sentences of this paragraph,
replace “Medicaid” with the statespecific term for Medicaid, if
applicable. If the state-specific
term does not include the word
“Medicaid,” plans should add
“(Medicaid)” after the first use of
the state-specific term.

Page 3, section titled:
“Second paragraph of
letter.”

Removed italics in this section and
edited the last sentence of the first
paragraph of this section.
If the denial involves a payment
request, insert the “payment for…”
text shown in the bracketed
heading options instruction to the
plan.

Corrected a reference to
the form and added
language based on
comments regarding using
“Medicaid” along with the
state specific term.

Corrected formatting and
changed language to
improve readability.

Instructions

Change to Instructions

Page 4, in “Section titled:
You have the right to
appeal our decision.”

Edited the following language in
the first paragraph of this section:

Page 5, in “Section titled:
There are two kinds of
appeals.”

Added the following sentence to
the end of this section:

Page 5, in “Section titled:
How to appeal.”

Moved the second paragraph to
the first paragraph and edited the
following language in this section:

…based on whether the coverage
decision is for a service or item
and whether the decision is for a
service/item that was a doctor or
another type of health care
provider ordered a doctor or other
health care provider ordered the
service/item described in the letter
and whether the denial is for a
service or item.

The plan should delete the last
paragraph in this section when
this letter is for a denial of a Part B
drug.

Throughout this section, the plan
should insert the proper terms
(“doctor,” or “health care provider,”
“service,” or “item”) as indicated
by the fields with in each instance
of pointed brackets,

Explanation
Changed to match
language used in the “how
to appeal” section later in
the instructions.

Added language to clarify
a plan instruction inserted
in the form.

Reordered language to
match the order of form.
Changed language to
match language used in
the “how to appeal” section
later in the instructions.

Page 5, in “Section titled:
How to appeal.”

Added “toll-free” in pointed
brackets before phone numbers.

Changed to match format
of the form.

Page 5, in “Section titled:
How to appeal.”

Added the following sentence:

Changed to provide
flexibility for a plan to insert
a plan-specific term when
applicable.

If the plan does not use the term
“Member Services,” the plan
should replace it with the term
they use.

Instructions
Page 5, in “Section titled:
How to appeal.”

Page 5, in “Section titled:
How to appeal.”

Change to Instructions
Added the following sentence:
The plan should insert the term
“Evidence of Coverage,” “Member
Handbook,” “Enrollee Handbook,”
or other term the plan uses in the
fields indicated by blue
instructional brackets to the plan.
Added the following language to
the last sentence in this section:

Explanation
Changed to correspond
with a change to the form.

Changed to improve
readability.

In the third sentence, the plan
should also insert the website
where members…
Page 5, in “Section titled:
How to appeal.”

Added the following sentence:

Page 6, in “Section titled:
What happens next.”

Added the following sentence to
the end of this section:

The plan may include a QR code
along with the web address.

If the state uses a different term
for Fair Hearing, the plan may
insert the state-specific term in
parentheses as indicated in the
blue instruction to the plan.

Changed to provide
flexibility for a plan to insert
a QR code.
Changed to provide
flexibility for a plan to insert
a state-specific term when
applicable.

Instructions
Page 6, in “Section titled:
Get help and more
information.”

Change to Instructions
Added the following sentences to
the end of the first bullet in this
section:
If the plan does not use the term
“Member Services,” the plan
should replace it with the term
they use. The plan should also
insert the plan’s web address in
the field. The plan
may use the web address that
provides information about the
plan’s appeals process. The plan
may include a QR code along with
the web address.

Page 7, in “Section titled:
Get help and more
information.”

Edited the following language in
the third bullet of this section:
The plan should also insert in the
appropriate field the state-specific
name and contact information for
the SHIP program in the state.

Page 7, in “Section titled:
Get help and more
information.”

Edited the following language in
the fourth bullet of this section:

Page 7, section titled: “End
of Document.”

Edited the section title as follows:

The plan should insert “Medicaid”
or the state-specific name for the
Medicaid agency and contact
information in the pointed brackets
appropriate field.

End of Letter Document footer

Explanation
Added to provide flexibility
for a plan to insert the plan
specific term for “member
services”, an appeals
specific web address when
available, and a QR code.

Changed to clarify how
plans should customize the
form.

Changed to clarify how
plans should customize the
form.

Changed section title to
clarify that the language
described in this section
should appear at the end
of the letter and not as a
document footer.

Instructions
Page 7, section titled: “End
of Document.”

Change to Instructions
Edited the following language in
this section:
At the end of the letter, the plan
should also include the toll-free
phone and TTY numbers and
hours of operation that members
and their doctors or
representatives should use to
obtain a copy of the letter in other
formats. At the end of the letter,
the plan should include
information on how to get the
letter for free in non-English
languages or alternate formats,
including the plan’s toll-free phone
and TTY numbers and days and
hours of operation. Plans should
insert the languages that they are
required to translate as indicated
in the field with pointed brackets.

Explanation
Changed to improve
readability and to more
closely align with other
CMS model notices
developed for MedicareMedicaid Plans under the
Financial Alignment
Initiative capitated model
demonstrations.