Track Change - Form Instructions

Form Instructions for the Applicable Integrated Plan Coverage Decision Letter CMS10716
What types of plans must use this letter?
Dual Eligible Special Needs Plans (“D-SNPs”) and affiliated Medicaid managed care
organizations (MCOs) that are “applicable integrated plans” must use this letter as provided
under 42 CFR 422.631(d).. “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.
When should the plan use this letter?
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, and/or Medicare Part B drug or
Medicaid drug or a request for payment of a medical service/item, and/or 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 DSNP 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.
Formatting, language, and other requirements
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The letter contains text in pointed brackets < > when the plan must insert particular
information into the document, and it is:
1. Based on the specific situation involved – for example, the appropriate term to be
inserted depends on the situation, or
2. 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, 202720275).

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When the letter gives the plan specific choices about word usage (e.g., ), 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:
1. Be in plain language, including short sentences, bulleted lists where appropriate, and
other means of making the information easy to read and understand.
2. Not consist solely of coding or technical terms, nomenclature, or other system-based
or otherwise plan-internal language or designations.

3.• When using the letter in a non-English language, text insertions in the letter mustshould
also be in that non-English language under 42 CFR 422.2267(a).. 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 under 42 CFR 422.629(k)..

•

Where contact information is required throughout the letter, include the number for the
relevant department or party that can best help the enrollee.

Required timeframes in this letter
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

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42 CFR 422.629(c). This letter includes instructions for timeframes where such replacements
are possible.
Heading instructions
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[IMPORTANT: For help with this notice, contact: at (TTY: ) OR at (TTY: )]: Plans must include this field if they
operate in a state that requires contact information at the top of the letter as provided
under 42 CFR 422.629(c).. For states that do not have this requirement, plans may
choose to include this information at the top of the 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.

First paragraph of letter
•

In the first sentence of this paragraph, insert the plan name.

•

In the second and third sentences of this paragraph, replace “Medicaid” with the statespecific 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.

Second paragraph of letter
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
approvedapproveddenied, 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:
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In the description of the medical service/item and/or Medicare Part B drug or Medicaid
drug being denied, partially approvedapproveddenied, reduced, stopped, suspended, or
changed, the plan should, in plain language, clearly and specifically list the medical
services/items affected.
o

Include the amount, duration, and scope of what the enrollee requested and the
outcome – denied, partially approvedapproveddenied, reduced, stopped, suspended,
or changed.

o

For services that are partially approvedapproveddenied, reduced, or changed,
include specifically what was requested and what is approved.

o

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.

o

If a benefit is reduced, the plan should specify the new amount of the service
permitted.

o

If a benefit is changed, the plan should explain what changed from the original
request and the approved service.

o

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 and/or Medicare Part B drug or Medicaid drug].”

Third paragraph of letter
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 and/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.

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If applicable, plans should include information on how or why the requested medical
service/item and/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.

Fourth paragraph of letter
In the sentence that states “Our plan will your on ,” 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 and/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 and/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.
Section titled: You have the right to appeal our decision
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 and/or
Medicare Part B drug or Medicaid drug described in the letter and whether the denial is for a
medical service/item and/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.

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Section titled: There are two kinds of appeals
Throughout this section, the plan must insert “7 calendar days” if the item is a Medicare Part B
drug that has not yet been received 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 under 42 CFR 422.629(c)..
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
Medicare Part B drug or if the state does not allow extensions.
Section titled: How to appeal
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 and/or Medicare Part B drug or Medicaid drug described in the letter and whether
the denial is for a medical service/item and/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 field and toll-free TTY number in the 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 field. The plan may include a QR code
along with the web address.
Section titled: How to keep getting your during your appeal
Plans have the option to remove this section if the decision relates to a medical service/item
and/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 and/or Medicare Part B drug or Medicaid
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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.
Section titled: What happens next
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 and/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.
Section titled: What to do if you need help with your appeal
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.
Section titled: Get help and more information
•

The plan should insert its name in the 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

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•
•
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with the term they use. The plan should also insert the plan’s web address in the 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.

End of Document
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.

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