CMS-10716 Integrated Coverage Decision Letter

Coverage Decision Letter
[IMPORTANT: For help with this notice, contact at (TTY: ) OR at (TTY: )]

[Insert Member name]
Member Health Plan ID:
Service/item this letter is about:
[Insert additional field(s) as needed or when required by state, such as provider or Member
Medicaid ID or date of decision]
is called “our plan” or “we” in this letter. We are a health plan that contracts with
Medicare and Medicaid [Replace with state-specific term for Medicaid, if applicable] to provide
coverage for both programs. Our plan coordinates your Medicare and Medicaid [Replace with
state-specific term for Medicaid, if applicable] services and your doctors, hospitals, pharmacies,
and other health care providers.
Our plan
[Insert if applicable: payment for] the listed below:
[Insert description of medical service/item or Part B drug or Medicaid drug, including
the amount, duration, and scope, of what the enrollee 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 the bathroom, or We previously approved 18 acupuncture
visits per year but are now reducing the visits to only allow 10.)]
[Insert if this is a post-service case for which there is no member 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].]
Our plan made this decision because [Provide a specific denial reason and a concise
explanation of why the medical service/item or Part B drug or Medicaid drug 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 medical service/item or

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

Part B drug or Medicaid drug 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].
[Insert if denial will result in a stoppage, suspension, or reduction of a medical service/item or
Medicare Part B drug or Medicaid drug the individual has already been receiving: Our plan will
your
on . See the “How to keep getting your during your appeal” section later in this letter for information about
continuing to receive your
during your appeal.]

You have the right to appeal our decision
You can appeal our plan’s decision. Share this letter with your
and ask about next steps. If you appeal and our plan changes its decision, we may pay for the
.
You can also call (TTY: ) and ask us
for a free copy of the information we used to make our decision. This may include health
records, guidelines, and other documents. You should show this information to your to help you decide if you should appeal.
You must appeal to our plan by [Insert specific appeal filing deadline date in month, date,
year format – 60 calendar days from date of letter. Insert deadline date in bold text]. Our plan
may give you more time if you have a good reason.

There are two kinds of appeals
Our plan has two kinds of appeals – standard appeals and fast appeals.
1. If you ask for a standard appeal, our plan will send you a written decision within [for a
Part B drug, insert: 7 calendar days or for any other medical service/item, insert: 30
calendar days or a shorter timeframe if required by the state] after we get your appeal.
2. If you ask for a fast appeal, our plan will give you a decision within [insert: 72 hours or a
shorter timeframe if required by the state] after we get your appeal. You can ask for a
fast appeal if you or your believe your health could be
seriously harmed by waiting up to [for a Part B drug, insert: 7 calendar days or for any
other medical service/item, insert: 30 calendar days or a shorter timeframe if required
by the state] for a decision. Our plan will automatically give you a fast appeal if your
asks for one for you or if your supports your request. If you ask for a fast appeal without support

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

from a , our plan will decide if you can get a fast appeal.
If our plan doesn’t approve a fast appeal, we’ll give you a decision on your appeal within
[for a Part B drug, insert: 7 calendar days or for any other medical service/item, insert:
30 calendar days or a shorter timeframe if required by the state].
[Delete if the letter is for a denial of a Part B drug or if the state does not allow extensions: For
both standard and fast appeals, our decision might take longer if you ask for more time or if we
need more information from you. Our plan will send you a letter and tell you if we need more
time and why.]

How to appeal
You, someone you named in writing as your representative to act on your behalf (such as a
relative, friend, or lawyer), or your can appeal. You can contact
our plan to appeal in one of these ways:
•

Phone: Call (TTY: )

•

Fax: Send a fax to

•

Mail: Mail it to

•

[Insert if appropriate: In person: Deliver it to ]

If you appeal in writing, keep a copy. If you call, we’ll send you a letter that says what you told
us on the phone.
When you appeal, you must give our plan:
•

Your name

•

Your address or an address where we should send information about your appeal (if you
don’t have a current address, you can still appeal)

•

Your member number with our plan

•

The reason(s) you’re appealing our decision

•

If you want a standard or a fast appeal. (For a fast appeal, tell us why you need one.)

•

Anything you want our plan to look at that shows why you need the . For example, you can send us:
o

Medical records from your ,

o

Letters from your (such as a statement from your
that says why you need a fast appeal), or

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

o

Other information that says why you need the

To get more information on how to appeal, call Member Services at (TTY: ). You can also find more information in
our plan’s [insert Evidence of Coverage, Member or Enrollee Handbook, or other term plan
uses], [plans may insert chapter and/or section reference, as applicable]. An up-to-date copy of
the [insert Evidence of Coverage, Member or Enrollee Handbook, or other term plan uses] is
always available on our website at or by calling our plan.

[Optional to delete this section if the decision relates to a medical service/item or Medicare Part
B drug or Medicaid drug that has not been received by the enrollee under a previous

How to
keep getting your during your appeal
authorization of the medical service/item or Medicare Part B drug or Medicaid drug:

If you’re already getting the
listed on the first page of this letter, you can ask to keep getting it during your appeal.
•

You must appeal and ask our plan to continue getting your by [Insert continuation of benefits request
filing date in month, date, year format. Date will be the later of the following: (1) 10
calendar days from date of letter (or later than 10 calendar days, if required by the state)
or (2) date the decision takes effect. Insert date in bold text].

•

See the “How to appeal” section earlier in this letter for information about how to contact
our plan.

•

If you ask our plan to continue your by [Insert continuation of benefits request filing date], your will stay the same during your
appeal.

•

If your is filing the appeal for you and you want to keep
getting your , then your
must include your written consent. ]

What happens next
After you appeal, our plan will send you an appeal decision letter to tell you if we approve or
deny your appeal. If our plan still denies [Insert if applicable: payment for] the listed on the first page of this Coverage Decision
Letter, the appeal decision letter will tell you what happens next, such as information about a

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

Medicare Level 2 appeal or how to ask for a Fair Hearing [Insert if appropriate:
(also called a )].

What to do if you need help with your appeal
You can get someone to appeal for you and act on your behalf. You must first name them in
writing as your “representative” by following the steps below. Your representative can be a
relative, friend, lawyer, doctor, health care provider, or someone else you trust.
If you want someone to appeal for you:
•

Call our plan at (TTY: )
to learn how to name that person as your representative. Or, you can visit
Medicare.gov/claims-appeals/file-an-appeal/can-someone-file-an-appeal-for-me. [Plans
may replace with a plan-specific web address that explains how enrollees can appoint a
representative.]

•

You and your representative must sign and date a statement that says this is what you
want.

•

Mail or fax the signed statement to us at:

•

Keep a copy.

Get help and more information
•

Member Services: Call
(TTY: ), . You can also visit .

•

[If the state uses an Ombudsman or other enrollee support program, insert the following
language, with state-specific information here: : Call (TTY: ). can answer questions if you
have a problem with your appeal. They can also help you understand what to do next.
They aren’t connected with our plan or with any insurance company or health plan. Their
services are free.]

•

: Call (TTY: ). counselors can help you
with Medicare issues, including how to appeal. isn’t
connected with any insurance company or health plan. Their services are free.

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

•

Medicare: Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week
(TTY users can call 1-877-486-2048). Or, visit Medicare.gov.

•

: Call (TTY: ).

•

Medicare Rights Center: Call 1-800-333-4114, or visit www.medicarerights.org.

•

Eldercare Locator: Call 1-800-677-1116, or visit www.eldercare.acl.gov to find help in
your community.

•

[If applicable, insert other state or local aging/disability resources contact information.]

You can get this document for free in [Insert, as appropriate: or]
other formats, such as large print, braille, or audio. Call . The call is free.
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/about-us/accessibility-nondiscrimination-notice, or call 1-800MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)

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 0938-1386 (Expires XX/XX/XXXX). This is a
mandatory information collection. 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, 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 Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS
Disclosure**** Please do not submit any documents containing sensitive information to the
PRA Reports Clearance Office. If you have questions or concerns regarding where to
submit your documents, please contact Kristi Sugarman Coats at [email protected].

Form CMS-10716

OMB Approval 0938-1386 (Expires: xx/xx/xxxx)