Notice of Denial of Medical Coverage Track Change

Notice of Denial of Medical Coverage

{Replace Denial of Medical Coverage with Denial of Payment, if applicable}
Date:

Member number:

Name:
[Insert other identifying information, as necessary (e.g., provider name, enrollee’s Medicaid
number, service subject to notice, date of service)]

Coverage for your medical services/items was Your request was {Insert
appropriate term: partially approved, denied}

We’ve {Insert appropriate term: denied, partially approved, stopped, reduced, suspended} the
{payment of} {medical services/items or Medicare Part B drug or Medicaid drug} listed below
thatrequested by you or your doctor [provider] requested:

Why was coveragedid we deny {Insert appropriate term: denied, partially
approved, stopped, reduced, suspended} your request?

We {Insert appropriate term: denied, partially approved, stopped, reduced, suspended} the
{payment of} {medical services/items or Medicare Part B drug or Medicaid drug} listed above
because {Provide specific rationale for decision and include State or Federal law and/or Evidence of
Coverage provisions to support decision}:

You should sShare a copy of this decision with your doctor [provider] and discuss next steps. If
your doctor [provider] asked for coverage on your behalf, we already sent them a copy of this
denial noticedecision.

You have the right to appeal our decision
You have the right to Aask {health plan name} to review our decision by asking us for an appeal
within 65 calendar days of the date listed at the top of this notice. If you ask for an appeal after
65 days of the date of this notice, you must explain why your appeal is late. See “How to ask for an
appeal with {health plan name}” on the next page. [Insert Medicaid information explaining plan
level appeal must be exhausted before asking for a State Fair Hearing or other state external
review.]
[If you need help getting a Medicaid service, asking for a Medicaid appeal, or would like to request
information to support your Medicaid appeal, contact {health plan name} at {Insert toll free and
TTY phone numbers} {Insert plan hours of operation}.]
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XX/XXXX)

Plan Appeal: Ask {health plan name} for an appeal within 65 calendar days of the date listed
at the top of this notice. If you ask for an appeal after 65 days of the date of this notice, you must
explain why your appeal is late. See “How to ask for an appeal with {health plan name}” on the
next page.
[How to keep your services while we review your case: If we’re stopping or reducing a
service, you can keep getting the service while your case is being reviewed. For If you want the
service to continue, you must ask for an appeal within 10 days of the date of this notice or
before the service is stopped or reduced, whichever is later. Your doctor [provider] must agree
that you should keepcontinue getting the service. If you lose your appeal, yYou may have to pay
for these services if you lose your appeal.]

If you want someone else to act for you
You can name a relative, friend, attorney, doctor [provider], or someone else to act as your
representative. If you want someone else to act for you, call us at: {number(s)} to learn how to
name your representative. TTY users call {number}. Both you and the person you want to act for
you must sign and date a statement confirming this is what you want. You’ll need to mail or fax
this statement to us.

Important Information About Your Appeal Rights
There are 2 kinds of appeals with {health plan name}
Standard Appeal
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Request for Service: For services you haven’t received yet, Wwe’ll give you a written
decision on a standard appeal within {insert appropriate timeframe for medical service/item
or Medicare Part B drug: 30 days, 7 days} [Insert timeframe for standard internal plan
Medicaid appeals, if different] after we get your appeal. [insert for requests for medical
service/item: Our decision might take longer if you ask for an extension, or if we need more
information about your case. We’ll tell you if we’re taking extra time and will explain why
more time is needed.]

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Request for Payment: For appeals related If your appeal is forto payment of a {medical
service/item or Medicare Part B drug} you already received, we’ll give you a written decision
within 60 days.

Fast Appeal (only available for service requests) –
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We’ll give you a decision on a fast appeal within 72 hours [Insert timeframe for expedited
internal plan Medicaid appeals, if different] after we get your appeal. You can ask for a fast
appeal if you or your doctor [provider] believe your health could be seriously harmed by
waiting for a standard appeal. up to {insert appropriate timeframe for medical service/item
or Part B drug: 30 days, 7 days} for a decision. You can’t ask for a fastn expedited appeal
if you’re asking us to pay you back for a {medical service/item or Medicare Part B drug} you
already received.

Formatted: Bulleted + Level: 1 + Aligned at: 0.25" +
Indent at: 0.5"

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We’ll automatically give you a fast appeal if a doctor [provider] asks for one for you or if
your doctor supports your request. If you ask fFor a fast appeal without support from a
doctor [provider], we’ll decide whetherif your request requires a fast appeal. If we don’t

Formatted: Bulleted + Level: 1 + Aligned at: 0.25" +
Indent at: 0.5"

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XX/XXXX)

give you a fast appeal, we’ll process a standard appeal.give you a decision within {insert
appropriate timeframe for medical service/item or Part B drug: 30 days, 7 days}.

How to ask for an appeal with {health plan name}
Step 1: You, your representative, or your doctor [provider] can ask us for an appeal. Your
{written} request must include:
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Your name
Address
Plan Member number
Reasons for appealing
Whether you want a sStandard or fFast aAppeal (for a fFast aAppeal, explain why you need
one).
Any evidence you want us to review, likesuch as medical records, doctor supporting
statements, s’ letters (such as a doctor’s supporting statement if you ask for a fast appeal),
or other information that explains why you need the {medical service/item or Medicare Part
B drug or Medicaid drug}. Call your doctor if you need this information.

If you’re asking for an appeal and missed the deadline, you can ask for an extension and should
include your reason for being late.
We recommend kKeeping a copy of everything you send us for your records. [Insert, if applicable:
You can ask to see the medical records and other documents we used to make our decision before
or during the appeal. At no cost to you, yYou can also ask for a copy of the guidelines we used to
make our decision at no cost to you.]
Step 2: Submit your appeal by Mmail, phone, fax, or onlinedeliver your appeal. {You can also call
us or submit your appeal online}
For a Standard Appeal: Mailing Address:
{Phone:}
Fax:

{CarrierIn Person Delivery Address:}
{TTY Users Call:}
{OnlineWebsite:}

{Insert, if applicable: If you ask for a standard appeal by phone, we’ll send you a letter confirming
what you told us.}
For a Fast Appeal:

Phone:
{Fax:}

{TTY Users Call:}
{OnlineWebsite:}

What happens next?
If you ask for an appeal and we continue to deny your request for {payment of} a {medical
service/item or Medicare Part B drug or Medicaid drug}, we’ll automatically send your case to an
independent reviewer. If the independent reviewer denies your request, the written decision will
explain if you have additional appeal rights.
[Insert additional State-specific Medicaid rules, as applicable.]

How to ask for a Medicaid State Fair Hearing

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XX/XXXX)

If [health plan name] denies your appeal request, you can ask for a State Fair Hearing. [States
may also have additional language regarding other external review processes.]
Step 1: You or your representative must ask for a State Fair Hearing (in writing) within (
) days
of the date of the notice that denies your appeal request. You have up to (
) days if you have a
good reason for making your request late.
Your
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•
•
•
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{written} request must include:
Your name
Address
Member number
Reasons for appealing
Any evidence you want us to review, such as medical records, doctors’ letters, or other
information that explains why you need the item or service. Call your doctor if you need this
information.

Step 2: Send your request to:

Address:
Phone:

Fax:

[A copy of this notice has been sent to:]

Get help & more information
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•
•
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{Health Plan Name} Toll Free:
TTY users call:
{Insert plan hours of operation} or {plan website}
Medicare: 1-800-MEDICARE (1-800-633-4227), 24 hours, 7 days a week. TTY users call:
1-877-486-2048
Medicare Rights Center: 1-888-HMO-9050
Elder Care Locator: 1-800-677-1116 or eldercare.acl.gov/Public/Index.aspx eldercare.acl.gov
to find help in your community
[Medicaid/State contact information]
{State or local aging/disability resources contact information}
State Health Insurance Program National Technical Assistance Center: call your
State Health Insurance Assistance Program for free, personalized health insurance
counseling. Visit SHIPhelp.org or call 1-877-839-2675 to get the number for your local
SHIP.877-839-2675

{May insert instructions for how enrollees can get this notice in an alternate language or format from the plan.}

Get information in another format
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XX/XXXX)

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/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users
can call 1-877-486-2048.

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 0938-0829.
This information collection is for the notice Medicare health plans must provide when a request for either a medical
service or payment is denied, in whole or in part. The time required to complete this information collection is estimated
to average less than 10 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, to review and complete the information collection. This information collection is mandatory
under Section 1852(g)(1)(B) of the Act and the regulatory authority set forth in Subpart M of Part 422 at 42 CFR
422.568, 422.572, 417.600(b), and 417.840. 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.

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 collection is
0938-0829. 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, and gather the data needed, and
complete and review the information collection. If you have any 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, Baltimore, Maryland 21244-1850.
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/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY
users can call 1-877-486-2048.

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: XX/XX/XXXX)