Crosswalk

Crosswalk for the substantive change to the CMS 10123

Current version of notice

If You Miss the Deadline to
Request an Immediate Appeal,
You May Have Other Appeal
Rights:
•

If you have Original
Medicare: Call the QIO
listed on page 1.

•

If you belong to a
Medicare health plan:
Call your plan at the
number given below.

Proposed version of notice
•

If you miss the
deadline to ask for
an immediate
appeal, you still
have appeal rights.

•

Call your QIO at
{insert QIO name
and toll-free
number of QIO} to
appeal, or if you
have questions.

Justification

This change reflects the policy
effective 1/1/2025, at 42 CFR
Part 422.626 (a)(2) 1 which
grants Medicare Advantage
(MA) enrollees the right to
appeal untimely to the QIO
(Quality Improvement
Organization), aligning the
appeals process for MA and
Original Medicare.

Plan contact
information_________

1

Medicare Program; Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare
Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health
Information Technology Standards and Implementation Specifications (CMS 4205-F).