Form CMS-10141 Model Precluded Provider Letter

Part C and D Model Precluded Provider Letter
[Instructions: This model letter could be used by Medicare plans and Part D plans to alert a member
that future medication fills prescribed or health care services furnished by his or her current provider
will no longer be covered because the individual or entity has been placed on CMS’s preclusion list, as
required by 42 CFR § 417.478(e), § 422.224(b), § 460.86(b), and § 423.120(c)(6)(iv)(B)(1). After
publication of the preclusion list, the Medicare plans or Part D plans should send a notice to ensure that
members who have previously received a prescription or care in the last 12 months from a precluded
provider receive a notice as soon as possible but no later than 30 calendar days after the publication of
the associated list or update. The plan must also ensure reasonable efforts are made to notify the
beneficiary’s provider of a beneficiary who was sent a notice. Plans are not required to use this version
for the required beneficiary notice, however, the letters should include the information specified in this
model notice.]

Dear :
This letter is to inform you that we can no longer cover [Insert all that apply
] for dates of service after [Effective Date Plan Claim
Rejections Begin] that are [Insert one ] by . [Insert if
applies ].
cannot cover [Insert as applicable < health care services>
] [Insert as applicable ] by as of [Effective Date Plan Claim Rejections Begin] because he/she has been placed on a
Medicare “preclusion list” by the Centers for Medicare & Medicaid Services (CMS). Medicare plans are
prohibited from making payment for [Insert as applicable <
prescriptions prescribed>] by individuals and entities on the preclusion list. For more information about
the preclusion list, you may visit CMS’s website at https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/Preclusion-List.
{Plan should insert one of the two sentences below.}
[Part C plans insert \: Please call Service at (TTY/TDD users
should call ) if you need assistance finding another provider in your area.] [Standalone Part D plans insert: Please call 1-800-Medicare (1-800-633-4227) (TTY users should call 1-877486-2048) if you need assistance finding another provider.] If you have further questions regarding the
status of your prescription(s), we are available from .
Sincerely,

Form CMS-10141

OMB Approval No. 0938-0964 (Expires 11/30/2021)

Last Updated
[Appropriate language, including disclaimers, is expected to appear in this model document.]

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 collection is 0938-0964. The time required to complete this information collection is estimated
to average 5 minutes per response, including the time to review instructions, search existing data resources,
and gather the data needed, and complete and review the information collection. If you have any 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, Baltimore, Maryland 21244-1850.
CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g.,
Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan,
call: 1-800-MEDICARE.

Form CMS-10141

OMB Approval No. 0938-0964 (Expires 11/30/2021)