Crosswalk - 60day

60-day Federal Register Crosswalk: High Level Summary of Revisions
The current Coverage Decision Letter expires 11/2023. We have made minor updates to the
letter that are listed below. The Coverage Decision Letter is issued to applicable integrated plan
enrollees when a request for a service or item is denied. The changes will not result in additional
burden.
Section

Change/Reason

Throughout
the
document

We updated the term ‘member’ to ‘enrollee’ throughout the document.

Header

We added a contact information field under the title that reads as follows:
[IMPORTANT: For help with this notice, contact: at (TTY: ) OR at (TTY: )].
Plans must include this field if they operate in a state that requires contact information at
the top of the letter. For states that do not have this requirement, plans may choose to
include this information at the top of the letter.

Header

We added “date of decision” to the field that allows plans to include information required
by the state. States may require plans to include the date the plan made their decision in
the ‘date of decision’ field.

Second
Paragraph

We added the disposition “changed” to the sentence “Our plan .” If a service is not fully
approved as requested and was changed (e.g., denied an out-of-network provider but
approved an in-network provider), using the term “changed” is a more appropriate
disposition for this sentence.

Second
Paragraph

We added additional instructional text for plans to use when completing this
section. This paragraph now reads: [Insert description of service or item,
including the amount, duration, and scope, of what the member requested (e.g.,
physical therapy visits 2 times per week for 1 year), and the outcome, denied,
partially denied, reduced, stopped, suspended, or changed, and include the doctor
or provider’s name if a particular doctor or provider requested the service or item.
If a service or item request is partially denied, reduced, or changed, include
specifically what was requested and what is approved (e.g., We are approving
acupuncture services for 3 months instead of a full year, or We are approving
moving a toilet to the south wall instead of the east wall of bathroom, or We
previously approved 18 acupuncture visits per year but are now reducing the
visits to only allow 10).]

Second
Paragraph
Third
Paragraph

Section
titled: How
to keep
getting your
service or
item during
your appeal

We added a statement for plans to use when the request is a post-service payment case
and the member has no liability, “Please note, you will not be billed or owe any money
for this [insert as applicable: medical service/item or Part B drug or Medicaid drug].”
We added additional instructional text for plans to use when completing this section.
This paragraph now reads: 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 in plain language. The plain language explanation of
the decision should include: (1) relevant context for the decision (e.g., if the service/item
was approved for the enrollee in the past, the description should include what was
previously approved, when it was approved and by whom, and what has changed or is
otherwise different now); (2) coverage information considered including Medicare and
Medicaid coverage benefits; and, (3) if applicable, information on how or why the
requested service or item is not supported by the enrollee’s needs – see instructions for
more information].

We added brackets to this section allowing plans to remove this paragraph if the decision
relates to a service or item that has not been received by the enrollee under a previous
authorization of the service or item.