Form CMS-10003 Notice of Denial of Medical Coverage

Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help,
you can call one of the numbers listed on the last page under “Get help & more information.”

Notice of Denial of Medical Coverage

{Replace Denial of Medical Coverage with Denial of Payment, if applicable}
Date:

Member number:

Name:
[Insert other identifying information, as necessary (e.g., provider name, enrollee’s Medicaid number, service
subject to notice, date of service)]

Your request was {Insert appropriate term: partially approved, denied }

We’ve {Insert appropriate term: denied, partially approved, stopped, reduced, suspended} the {payment of}
{medical services/items or Part B drug or Medicaid drug} listed below requested by you or your doctor
[provider]:

Why did we deny your request?

We {Insert appropriate term: denied, partially approved, stopped, reduced, suspended} the {payment of} {medical
services/items or Part B or Medicaid drug} listed above because {Provide specific rationale for decision and
include State or Federal law and/or Evidence of Coverage provisions to support decision}:

You should share a copy of this decision with your doctor so you and your doctor can discuss next steps. If your
doctor requested coverage on your behalf, we have sent a copy of this decision to your doctor.

You have the right to appeal our decision

You have the right to ask {health plan name} to review our decision by asking us for an appeal. [Insert Medicaid
information explaining plan level appeal must be exhausted prior to requesting State Fair Hearing or other state
external review.]
Plan Appeal: Ask {health plan name} for an appeal within 60 days of the date of this notice. We can give you
more time if you have a good reason for missing the deadline. See section titled “How to ask for an appeal with
{health plan name}” for information on how to ask for a plan level appeal.

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XXXX)

How to keep your services while we review your case: If we’re stopping or reducing a service,
you can keep getting the service while your case is being reviewed. If you want the service to
continue, you must ask for an appeal within 10 days of the date of this notice or before the
service is stopped or reduced, whichever is later. Your provider must agree that you should
continue getting the service. If you lose your appeal, you may have to pay for these services.

If you want someone else to act for you

You can name a relative, friend, attorney, doctor, or someone else to act as your representative. If you want
someone else to act for you, call us at: {number(s)} to learn how to name your representative. TTY users call
{number}. Both you and the person you want to act for you must sign and date a statement confirming this is what
you want. You’ll need to mail or fax this statement to us. Keep a copy for your records.

Important Information About Your Appeal Rights

There are 2 kinds of appeals w ith { health plan nam e}
Standard Appeal – We’ll give you a written decision on a standard appeal within {insert appropriate timeframe
for medical service/item or Part B drug: 30 days, 7 days} [Insert timeframe for standard internal plan Medicaid
appeals, if different] after we get your appeal. Our decision might take longer if you ask for an extension, or if we
need more information about your case. We’ll tell you if we’re taking extra time and will explain why more time
is needed. If your appeal is for payment of a {medical service/item or Part B drug} you’ve already received, we’ll
give you a written decision within 60 days.
Fast Appeal – We’ll give you a decision on a fast appeal within {insert appropriate timeframe for medical
service/item or Part B or Medicaid drug: 72 hours, 24 hours} after we get your appeal. You can ask for a fast
appeal if you or your doctor believe your health could be seriously harmed by waiting up to 30 days for a decision.
You cannot request an expedited appeal if you are asking us to pay you back for a {medical service/item or Part B
drug} you’ve already received.
We’ll automatically give you a fast appeal if a doctor asks for one for you or if your doctor supports your
request. If you ask for a fast appeal without support from a doctor, we’ll decide if your request requires a fast
appeal. If we don’t give you a fast appeal, we’ll give you a decision within 30 days.

How to ask for an appeal with {health plan name}
Step 1: You, your representative, or your doctor [provider] must ask us for an appeal. Your {written} request
must include:
•
•
•
•
•
•

Your name
Address
Member number
Reasons for appealing
Whether you want a Standard or Fast Appeal (for a Fast Appeal, explain why you need one).
Any evidence you want us to review, such as medical records, doctors’ letters (such as a doctor’s
supporting statement if you request a fast appeal), or other information that explains why you need the
{medical service/item or Part B drug or Medicaid drug}. Call your doctor if you need this information.

If you’re asking for an appeal and missed the deadline, you may include your reason for being late.
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XXXX)

We recommend keeping a copy of everything you send us for your records. [Insert, if applicable: You can ask to
see the medical records and other documents we used to make our decision before or during the appeal. At no
cost to you, you can also ask for a copy of the guidelines we used to make our decision.]
Step 2: Mail, fax, or deliver your appeal. {You can also call us or submit your appeal electronically}
For a Standard Appeal:

Mailing Address:
{Phone:}
Fax:

{In Person Delivery Address:}
{TTY Users Call:}
{Website:}

{Insert, if applicable: If you ask for a standard appeal by phone, we will send you a letter confirming what you
told us.}
For a Fast Appeal: Phone:
{Fax:}

{TTY Users Call:}
{Website:}

What happens next?

If you ask for an appeal, we will send you another letter with a decision to tell you if we approve or deny your
request. If we continue to deny your request for {payment of} a {medical service/item or Part B drug or Medicaid
drug}, we’ll send you a written decision and automatically send your case to an independent reviewer. If the
independent reviewer denies your request, the written decision will explain if you have additional appeal
rights.
[Insert additional State-specific Medicaid rules, as applicable.]

How to ask for a M edicaid State Fair Hearing
If [health plan name] denies your appeal request, you can take the steps listed below to request a
State Fair Hearing. [States may also have additional language regarding other external review
processes.]
Step 1: You or your representative must ask for a State Fair Hearing (in writing) within ( ) days
of the date of the notice that denies your appeal request. You have up to ( ) days if you have a
good reason for your request being late.
Your {written} request must include:
• Your name
• Address
• Member number
• Reasons for appealing
• Any evidence you want us to review, such as medical records, doctors’ letters, or other
information that explains why you need the item or service. Call your doctor if you need this
information.
Step 2: Send your request to:

Address:
Phone:

Fax:

[A copy of this notice has been sent to:]

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XXXX)

Get help & more information
•
•
•
•
•
•

{Health Plan Name} Toll Free:
TTY users call:
{Insert plan hours of operation} or {plan website}
1-800-MEDICARE (1-800-633-4227), 24 hours, 7 days a week. TTY users call: 1-877-486-2048
Medicare Rights Center: 1-888-HMO-9050
Elder Care Locator: 1-800-677-1116 or www.eldercare.acl.gov to find help in your community.
[Medicaid/State contact information]
{State or local aging/disability resources contact information}

{May insert instructions for how enrollees can receive this notice in an alternate language or format from the plan.}
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 0938-0829. The time
required to complete this information collection is estimated to average 10 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.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also
have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY
users can call 1-877-486-2048.
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XXXX)