Burden Estimates - Appeals

Model Notice of Adverse Benefit Determination – Revised as of June 22, 2011
OMB Control No.: 0938-1099
Expiration Date: xx/20xx

Date of Notice
Name of Plan
Address

Telephone/Fax
Website/Email Address

This document contains important information that you should retain for your records.
This document serves as notice of an adverse benefit determination. We have declined to
provide benefits, in whole or in part, for the requested treatment or service described below. If
you think this determination was made in error, you have the right to appeal (see the back of this
page for information about your appeal rights).
Case Details:
ID Number:
Patient Name:
Address: (street, county, state, zip)
Claim #:

Date of Service:

Provider:
Reason for Denial (in whole or in part):
Amt.
Charged

Allowed
Amt.

Other
Insurance

Deductible Co-pay

Coinsurance Other Amts. Amt. Paid
Not Covered

YTD Credit toward Deductible:

YTD Credit toward Out-of-Pocket Maximum:

Description of service:

Denial Codes:

[If denial is not related to a specific claim, only name and ID number need to be included in the
box. The reason for the denial would need to be clear in the narrative below.]
Explanation of Basis for Determination:
If the claim is denied (in whole or in part) and there is more explanation for the basis of the
denial, such as the definition of a plan or policy term, include that information here.
[Insert language assistance disclosure here, if applicable.

SPANISH (Español): Para obtener asistencia en Español, llame al [insert telephone number].
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].

如果需要中文的帮助，请拨打这个号码 [insert telephone number].
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].
CHINESE (中文):

Important Information about Your Appeal Rights
What if I need help understanding this denial?
Contact us at [insert contact information] if you need
assistance understanding this notice or our decision to
deny you a service or coverage.

Can I provide additional information about my
claim? Yes, you may supply additional information.
[Insert any applicable procedures for submission of
additional information.]

What if I don’t agree with this decision? You have a
right to appeal any decision not to provide or pay for
an item or service (in whole or in part).

Can I request copies of information relevant to my
claim? Yes, you may request copies (free of charge).
If you think a coding error may have caused this claim
to be denied, you have the right to have billing and
diagnosis codes sent to you, as well. You can request
copies of this information by contacting us at [insert
contact information].

How do I file an appeal? [Complete the bottom of
this page, make a copy, and send this document to
{insert address}.] [or] [insert alternative instructions]
See also the “Other resources to help you” section of
this form for assistance filing a request for an appeal.
What if my situation is urgent? If your situation
meets the definition of urgent under the law, your
review will generally be conducted within 72 hours.
Generally, an urgent situation is one in which your
health may be in serious jeopardy or, in the opinion of
your physician, you may experience pain that cannot
be adequately controlled while you wait for a decision
on your appeal. If you believe your situation is urgent,
you may request an expedited appeal by following the
instructions above for filing an internal appeal and also
[insert instructions for filing request for simultaneous
external review)].
Who may file an appeal? You or someone you name
to act for you (your authorized representative) may file
an appeal. [Insert information on how to designate an
authorized representative.]

What happens next? If you appeal, we will review
our decision and provide you with a written
determination. If we continue to deny the payment,
coverage, or service requested or you do not receive a
timely decision, you may be able to request an external
review of your claim by an independent third party,
who will review the denial and issue a final decision.
Other resources to help you: For questions about
your rights, this notice, or for assistance, you can
contact: [if coverage is group health plan coverage,
insert: the Employee Benefits Security Administration
at 1-866-444-EBSA (3272)] [and/or] [if coverage is
insured, insert State Department of Insurance contact
information]. [Insert, if applicable in your state:
Additionally, a consumer assistance program can help
you file your appeal. Contact [insert contact
information].]

Appeal Filing Form
NAME OF PERSON FILING APPEAL:
Circle one: Covered person  Patient  Authorized Representative
Contact information of person filing appeal (if different from patient)
Address:
Daytime phone:
Email:
If person filing appeal is other than patient, patient must indicate authorization by signing here:
Are you requesting an urgent appeal? Yes  No
Briefly describe why you disagree with this decision (you may attach additional information, such as a
physician’s letter, bills, medical records, or other documents to support your claim):

Send this form and your denial notice to: [Insert name and contact information]
Be certain to keep copies of this form, your denial notice, and all documents and correspondence related
to this claim.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1099 (Expires XX/XX/XXXX). The time required to complete this information collection is
estimated to average 11 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail StopC4-26-05, Baltimore, Maryland 21244-1850.