10112023 - (03) Insufficient Documentation - Final 60-day Letter

Date

Address:

Case Number:

Dear requester:

This letter is to inform you that there is insufficient documentation for the Program to make a determination concerning your eligibility for CICP benefits in the Request for Benefits Package (Request Package) that you filed, on behalf of [Injured Countermeasure Recipient’s Representative] regarding [Injured Countermeasure Recipient’s name], with the U.S. Department of Health and Human Services’ (HHS) Countermeasures Injury Compensation Program (CICP or the Program). See 42 C.F.R. §110.71. You must submit the necessary documentation, identified below, to the CICP within 60 calendar days from the date of this letter. If insufficient documentation is submitted in response to this letter, the CICP may disapprove the Request for Benefits. 42 C.F.R. § 110.71.

Background

Upon receipt of your Request Package and the medical records indicated on the submitted Authorization for Use or Disclosure of Health Information form(s), CICP conducted an initial review of the medical documentation submitted and identified that medical records concerning the Request Package had been submitted. You were sent a letter notifying you that your Request Package had been received and if you had any additional documentation to submit for consideration, you should do so, otherwise your Request Package would proceed to the next phase of the medical eligibility review process with the documentation that had been received. You did not submit any additional documentation. While conducting a more thorough evaluation of the medical history associated with your claim, the reviewer identified that there were significant gaps in the medical records, as more fully discussed below. Therefore, CICP is now notifying you that there is insufficient documentation to make an eligibility determination and giving you an opportunity to provide the necessary additional documentation.

Documentation Received

The CICP has received the following documents pertaining to your claim for CICP benefits:

Medical Records Received Date To - From

Documentation Required But Not Yet Received

COMMENTS: [ADD CASE SPECIFIC INFORMATION CONCERNING THE MISSING RECORDS]

The CICP prefers that medical records are sent directly to the program by your health care provider(s). The indicated required documentation should be sent directly to the CICP online at injurycompensation.hrsa.gov (preferred). If unable to submit electronically, please send them to the following address:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

If you are unable to provide the required additional documentation, you may provide a written explanation of the reason(s) that the requested documentation is unavailable and the efforts you have made to obtain the documentation. 42 C.F.R. §§ 110.50(c); 110.71. The CICP may accept such a statement in place of the required documentation or disapprove the Request for Benefits due to insufficient documentation.

If you have questions, please call 1-855-266-2427, email [email protected], or mail them to the address above.

Sincerely,

CDR George Reed Grimes, MD, MPH

Director, Division of Injury Compensation Programs

Health Resources and Services Administration

www.hrsa.gov