Dual Eligible Special Needs Plans (“D-SNPs”) and affiliated Medicaid managed care organizations (MCOs) that are “applicable integrated plans” must use this letter. “Applicable integrated plans” are D-SNPs and affiliated MCOs with exclusively aligned enrollment that meet the criteria at 42 CFR 422.561. Applicable integrated plans are hereinafter referred to as “plans” in these instructions.
Plans must complete and issue this letter to enrollees when, as a result of an integrated organization determination under 42 CFR 422.631, they reduce, stop, suspend, deny, or change, in whole or in part, a request for a medical service/item, Medicare Part B drug or Medicaid drug or a request for payment of a medical service/item, Medicare Part B drug or Medicaid drug the enrollee has already received. This letter must be used in place of the Notice of Denial of Medical Coverage (or Payment) form (CMS-10003-NDMCP).
Plans should not send this letter when the request for a service or item is fully covered by the D-SNP or affiliated MCO, either under the Medicare or Medicaid benefit. Additionally, this letter must not be used for Medicare Part D denials. Plans will continue to use form CMS-10146, Notice of Denial of Medicare Part D Prescription Drug Coverage, for Part D denials.
The letter contains text in pointed brackets < > when the plan must insert particular information into the document, and it is:
Based on the specific situation involved – for example, the appropriate term to be inserted depends on the situation, or
Specific to the individual letter – for example, an effective date or deadline date.
Instructions to plans appear in blue italicized text and brackets [ ] and are only for plan use. Plans must ensure that no blue italicized text remains and that blue non-italicized text is changed to black text in the Coverage Decision Letters that plans send to enrollees.
The OMB control number must be displayed on the letter.
The letter must be provided in 12-point Times New Roman font equivalent or larger.
Dates should be written in month, date, year format (for example: May 14, 2025).
When the letter gives the plan specific choices about word usage (e.g., <medical service/item or Medicare Part B drug or Medicaid drug> <doctor or health care provider>), the plan should choose the term that fits the circumstances and use it consistently throughout the notice.
Any free text insertions should be written in a way that is understandable by a layperson (to the extent possible). The text should:
Be in plain language, including short sentences, bulleted lists where appropriate, and other means of making the information easy to read and understand.
Not consist solely of coding or technical terms, nomenclature, or other system-based or otherwise plan-internal designations.
When using the letter in a non-English language, text insertions in the letter should also be in that non-English language. These insertions should be in plain language and use terminology familiar to the specific Limited English Proficiency (LEP) populations served by the plan. Plans may consult https://www.cms.gov/outreach-and-education/outreach/writing-guidelines for more information.
Plans should take steps to ensure that enrollees can understand the letter, including conducting routine consumer testing of plan language with LEP individuals and modifying language as needed based on testing results.
Upon request of the enrollee, their representative, or the ombudsman program, plans must provide the enrollee’s case file, including medical records, documents such as Medicare and Medicaid coverage criteria and the Evidence of Coverage/Member or Enrollee Handbook, care coordination notes relevant to the request, and any new or additional evidence considered to make the decision, free of charge as provided under 42 CFR 422.633(c).
Plans must review all relevant coverage information prior to making the decision, including relevant Medicare and Medicaid coverage criteria, the enrollee’s care plan and other care coordination information, and the Evidence of Coverage/Member or Enrollee Handbook.
Plans operating in states that have established shorter timelines for a plan to make a decision on an appeal must replace any relevant timeframes with those set by the state. These timeframes must be documented in the plan’s state Medicaid agency contract as provided under 42 CFR 422.629(c). This letter includes instructions for timeframes where such replacements are possible.
[IMPORTANT: For help with this notice, contact: <Plan Name> at <Plan customer service phone number> (TTY: <TTY number>) OR <Ombudsman or other program office> at <phone number> (TTY: <TTY number>)]: 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.
<Date of Letter>: Insert the date the letter is issued in month, date, year format.
[Insert Member name]: Insert the member’s full name.
Member Health Plan ID: Insert the member’s health plan identification number. The member’s Medicare Beneficiary Identifier (MBI) should not be used.
Service/item this letter is about: Insert the name and/or brief descriptor of the service or item that was requested and for which authorization and/or payment is being denied.
[Insert additional field(s) as needed or when required by state, such as provider or Member Medicaid ID or date of decision]: The plan is permitted to insert additional fields of information in the header section of the letter if needed, consistent with applicable state requirements, such as the name of the provider making the request, the member’s Medicaid number, or the date of decision. If the plan operates in a state that requires contracted plans to include additional fields in this heading, add those fields.
In the first sentence of this paragraph, insert the plan name.
In the second and third sentences of this paragraph, replace “Medicaid” with the state-specific term for Medicaid, if applicable. If the state-specific term does not include the word “Medicaid,” plans should add “(Medicaid)” after the first use of the state-specific term.
The plan should insert in bold text the appropriate terms in the fields listed in this paragraph to describe the action taken; that is, whether the service was denied, partially denied, reduced, stopped, changed, or, in the case of a Medicaid service, suspended (temporarily stopping a service). If the denial involves a payment request, insert the “payment for” text shown in the blue instruction to the plan.
Below the second paragraph:
In the description of the medical service/item or Medicare Part B drug or Medicaid drug being denied, partially denied, reduced, stopped, suspended, or changed, the plan should, in plain language, clearly and specifically list the medical services/items affected.
Include the amount, duration, and scope of what the enrollee requested and the outcome – denied, partially denied, reduced, stopped, suspended, or changed.
For services that are partially denied, reduced, or changed, include specifically what was requested and what is approved.
If the plan suspends a service, the plan should explain what “suspended” means and whether the benefit is suspended permanently or for a particular time period.
If a benefit is reduced, the plan should specify the new amount of the service permitted.
If a benefit is changed, the plan should explain what changed from the original request and the approved service.
If the denial involves a payment request and there is no member liability insert the bold text “You will not be billed or owe any money for this [insert as applicable: medical service/item or Part B drug or Medicaid drug].”
In the sentence that begins, “Our plan made this decision because,” the plan should provide a specific denial reason and a concise explanation of why the medical service/item or Medicare Part B drug or Medicaid drug was denied and include state or federal law and/or Evidence of Coverage/Member or Enrollee Handbook provisions and plan policies/procedures or assessment tools used to support the decision.
This explanation should be in plain language and give, at a minimum, a basic explanation of the reasoning behind the action in the simplest language possible without losing meaning. It should also include a specific explanation about what information is needed to approve coverage.
Plans may provide a brief description of any Medicare or Medicaid coverage rule or plan policy included in the explanation. If the plan considered both Medicare and Medicaid coverage rules in making its decision, the description should include both sets of rules.
Plans are encouraged to include a brief explanation of how the determination to discontinue or reduce coverage was made. If the plan considered both Medicare and Medicaid coverage rules, the explanation should describe how both coverage rules were applied in this case.
If applicable, plans should include information on how or why the requested medical service/item or Medicare Part B drug or Medicaid drug is not supported by the enrollee’s needs (e.g., your medical records do not show that past acupuncture visits have helped you improve).
If the denial is for a Medicaid service/item that is not covered by the plan but is covered by another payer, such as a specific behavioral health service, the explanation should instruct the enrollee how to obtain coverage by providing contact information for the covering payer. The explanation should also offer to help the enrollee seek coverage for the service/item and provide contact information for where such assistance can be obtained.
In the sentence that states “Our plan will <reduce or stop or suspend> your <medical service/item or Medicare Part B drug or Medicaid drug> on <effective date>,” the plan should insert the effective date of the decision if the decision resulted 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. The effective date should be at least 10 days after the date the letter was issued or a longer period if required by the state. If the decision is in regard to a medical service/item or Medicare Part B drug or Medicaid drug that has not yet been received (for example, the denial is for a request for prior authorization), the plan should remove this paragraph.
The plan should insert the proper term (“doctor,” “health care provider,” “medical service/item,” “Medicare Part B drug,” or “Medicaid drug”) in each instance of pointed brackets in this section, based on whether a doctor or other health care provider ordered the medical service/item or Medicare Part B drug or Medicaid drug described in the letter and whether the denial is for a medical service/item or Medicare Part B drug or Medicaid drug .
In the second paragraph, the plan should insert the most appropriate plan phone and TTY numbers for appeal requests. The plan may insert the toll-free Member Services phone number and toll-free TTY number if the plan doesn’t have a specific phone number for appeal requests.
In the “You must appeal to our plan by” sentence, the plan should insert the appeal filing deadline date in the field indicated by the blue instruction to the plan. The appeal filing deadline date is 65 calendar days from the date of the letter. For example, if the letter is dated March 15, the Date of Letter will be March 15, and the appeal filing deadline date will be May 19. The plan should enter the deadline in month, date, year format. The plan should insert the deadline in bold text.
Throughout this section, the plan must insert “7 calendar days” if the item is a Part B drug or “30 calendar days” for all other medical services/items, as indicated in the blue instruction to the plan. Plans operating in states with shorter timelines to make a decision on an appeal must replace any relevant timeframes with those established by the state and documented in the state Medicaid agency contract.
Throughout this section, the plan should insert proper terms (“doctor” or “health care provider”) as indicated by the fields with pointed brackets, based on whether a doctor or other health care provider ordered the service described in the letter.
The plan should delete the last paragraph in this section when this letter is for a denial of a Part B drug or if the state does not allow extensions.
Throughout this section, the plan should insert the proper term (“doctor,” “health care provider,” “medical service/item,” “Medicare Part B drug,” or “Medicaid drug”) in each instance of pointed brackets, based on whether a doctor or other health care provider ordered the medical service/item or Medicare Part B drug or Medicaid drug described in the letter and whether the denial is for a medical service/item or Medicare Part B drug or Medicaid drug.
The plan should insert the most appropriate plan phone and TTY numbers, fax number, mailing address, and, if appropriate, the in-person delivery address that enrollees may use to file an appeal. The plan may insert the toll-free Member Services phone number and toll-free TTY number if the plan doesn’t have a specific phone number for appeal requests.
In the paragraph that starts, “To get more information on how to appeal,” the plan must insert the plan’s toll-free Member Services phone number in the <toll-free plan Member Services phone number> field and toll-free TTY number in the <toll-free TTY number> field. If the plan does not use the term “Member Services,” the plan should replace it with the term they use. The plan should insert the term “Evidence of Coverage,” “Member Handbook,” “Enrollee Handbook,” or other term the plan uses in the fields indicated by the blue instruction to the plan. In the second sentence, the plan may also include additional chapter and/or section reference information, as applicable. In the third sentence, the plan should also insert the website where enrollees can access the most current version of the plan’s Evidence of Coverage/Member or Enrollee Handbook document in the <web address> field. The plan may include a QR code along with the web address.
Plans have the option to remove 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 authorization of the medical service/item or Medicare Part B drug or Medicaid drug. Throughout this section, the plan should insert the proper term (“medical service/item,” “Medicare Part B drug,” “Medicaid drug,” “doctor,” or “health care provider”) as indicated in the fields with pointed brackets.
The plan should insert the continuation of benefits request deadline date in the fields indicated by the blue instruction to the plan. The continuation of benefits deadline date is one of the following, whichever is later:
10 calendar days from the date of the letter (or later than 10 calendar days, if required by the state)
The effective date of the decision
The continuation of benefits request deadline date should be inserted in month, date, year format and, for the first instance, in bold text.
If the denial involves a payment request, insert the “payment for“ text shown in the blue instruction to the plan. The plan should insert the proper term (“medical service/item,” “Medicare Part B drug,” or “Medicaid drug”) as indicated in the fields with pointed brackets, based on whether the denial is for a medical service/item or Medicare Part B drug or Medicaid drug. The plan should insert the state name as indicated in the fields with pointed brackets. If the state uses a different term for Fair Hearing, the plan may insert the state-specific term in parentheses as indicated in the blue instruction to the plan.
In the first bullet in this section, the plan should insert the most appropriate plan phone and TTY numbers in the fields with pointed brackets to be used if the enrollee needs information on how to name an authorized representative for the purposes of the appeal. The plan may insert the toll-free Member Services phone number and toll-free TTY number if the plan doesn’t have a specific phone number for authorized representative requests. The plan may also replace the Medicare.gov web address with a plan-specific web address that explains how enrollees can appoint a representative.
In the third bullet in this section, the plan should insert, in the appropriate fields, the mailing address and fax number that may be used to submit authorized representative requests.
The plan should insert its name in the <plan name> field, the plan’s Member Services toll-free phone and TTY numbers, along with days and hours of operation, for the enrollee, doctor, health care provider, or representative to call if they need information or help with the appeal process in the appropriate fields, as designated by pointed brackets. If the plan does not use the term “Member Services,” the plan should replace it with the term they use. The plan should also insert the plan’s web address in the <plan website> field. The plan may use the web address that provides information about the plan’s appeals process. The plan may include a QR code along with the web address.
If the state uses an Ombudsman or other enrollee support program, the plan should insert the name and contact information for the Ombudsman or other enrollee support program in the appropriate field. If the state doesn’t use an Ombudsman or other enrollee support program, this bullet should be removed.
The plan should insert in the appropriate field the state-specific name and contact information for the SHIP program in the state.
The plan should insert “Medicaid” or the state-specific name for the Medicaid agency and contact information in the appropriate field.
If applicable, the plan should also insert the name(s) and contact information of any other state/local disability and aging services agency(ies) that provide(s) unbiased assistance with plan appeals.
At the end of the letter, the plan should include information on how to get the letter for free in non-English languages or alternate formats, including the plan’s toll-free phone and TTY numbers and days and hours of operation. Plans should insert the languages that they are required to translate as indicated in the field with pointed brackets. The plan should also include the nondiscriminatory language disclaimer that is required on CMS forms and notices.
Form CMS-10716 OMB Approval 0938-1386 (Expires: 11/30/2025)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2024 Dual Eligible Special Needs Coverage Decision Letter Paperwork Reduction Act Package Form Instructions |
| Subject | 2024 PRA DSNP CDL Form Instructions |
| Author | CMS/MMCO |
| File Modified | 0000-00-00 |
| File Created | 2024-07-19 |