Track Change - DSNPCoverageDecisionLetterIntegrated

Coverage Decision Letter
[IMPORTANT: For help with this notice, contact at (TTY: ) OR at (TTY: )]

Formatted: Font: Not Italic
Formatted: Font: Not Italic

[Insert Member name]
Member Health Plan ID:
Service/item this letter is about:
[Insert additional field(s) as needed or when required by state, such as provider or Member
Medicaid ID or date of decision]
is called “our plan” or “we” in this letter. We are a health plan that contracts with
Medicare and Medicaid [Replace with state-specific term for Medicaid, if applicable] to provide
coverage for both programs. Our plan coordinates your Medicare and Medicaid [Replace with
state-specific term for Medicaid, if applicable] services and your doctors, hospitals, pharmacies,
and other health care providers.
Our plan [Insert if applicable: payment for] the listed below:
[Insert description of medical service/item and/or Medicare Part B drug or Medicaid
drug, including the amount, duration, and scope, of what the enrollee requested
(e.g., physical therapy visits 2 times per week for 1 year), and the outcome, denied,
partially approvedapproveddenied, reduced, stopped, suspended, or changed, and
include the doctor or provider’s name if a particular doctor or provider requested the
service or item. If a service or item request is partially approvedapproveddenied,
reduced, or changed, include specifically what was requested and what is approved
(e.g., We are approving acupuncture services for 3 months instead of a full year, or
We are approving moving a toilet to the south wall instead of the east wall of the
bathroom, or We previously approved 18 acupuncture visits per year but are now
reducing the visits to only allow 10.)]
[Insert if this is a post-service case for which there is no member liability: Please note, 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].]

Formatted: Font: Italic

Our plan made this decision because [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 to support the decision in plain language. The plain language explanation

Formatted: Font: Not Bold

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Font: Italic
Formatted: Font: Not Bold, Italic

of the decision should include: (1) relevant context for the decision (e.g., if the medical
service/item and/or Medicare Part B drug or Medicaid drug was approved for the enrollee in the
past, the description should include what was previously approved, when it was approved and
by whom, and what has changed or is otherwise different now); (2) coverage information
considered including Medicare and Medicaid coverage benefits; and, (3) if applicable,
information on how or why the requested service or item is not supported by the enrollee’s
needs – see instructions for more information].
[Insert if denial will result 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: Our
plan will your on . See the “How to keep getting your during your appeal” section later in
this letter for information about continuing to receive your during your appeal.]

Formatted: Font: Not Bold, Italic
Formatted: Font: Italic
Formatted: Font: Italic

You have the right to appeal our decision
You can appeal our plan’s decision. Share this letter with your
and ask about next steps. If you appeal and our plan changes its decision, we may pay for the
.
You can also call (TTY: ) and ask us
for a free copy of the information we used to make our decision. This may include health
records, guidelines, and other documents. You should show this information to your to help you decide if you should appeal.
You must appeal to our plan by [Insert specific appeal filing deadline date in month, date,
year format – 65 calendar days from date of letter. Insert deadline date in bold text]. This date
applies if you request a standard or a fast appeal. Our plan may give you more time if you have
a good reason.

There are two kinds of appeals
Our plan has two kinds of appeals – standard appeals and fast appeals.
1. If you ask for a standard appeal, our plan will send you a written decision within [for a
Medicare Part B drug the enrollee has not yet received, insert: 7 calendar days and/or
for any other medical service/item, insert: 30 calendar days or a shorter timeframe if
required by the state] after we get your appeal.
2. If you ask for a fast appeal, our plan will give you a decision within [insert: 72 hours or a
shorter timeframe if required by the state] after we get your appeal. You can ask for a
fast appeal if you or your believe your health could be
seriously harmed by waiting up to [for a Medicare Part B drug, insert: 7 calendar days
Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Font: Italic
Formatted: Font: Italic

Formatted: Font: Not Bold

and/or for any other medical service/item, insert: 30 calendar days or a shorter
timeframe if required by the state] for a decision. Our plan will automatically give you a
fast appeal if your asks for one for you or if your
supports your request. If you ask for a fast appeal
without support from a , our plan will decide if you can
get a fast appeal. If our plan doesn’t approve a fast appeal, we’ll give you a decision on
your appeal within [for a Medicare Part B drug, insert: 7 calendar days and/or for any
other medical service/item, insert: 30 calendar days or a shorter timeframe if required
by the state].
[Delete if the letter is for a denial of a Medicare Part B drug or if the state does not allow
extensions: For both standard and fast appeals, our decision might take longer if you ask for
more time or if we need more information from you. Our plan will send you a letter and tell you if
we need more time and why.]

How to appeal
You, someone you named in writing as your representative to act on your behalf (such as a
relative, friend, or lawyer), or your can appeal. You can contact
our plan to appeal in one of these ways:
•

Phone: Call (TTY: )

•

Fax: Send a fax to

•

Mail: Mail it to

•

[Insert if appropriate: In person: Deliver it to ]

If you appeal in writing, keep a copy. If you call, we’ll send you a letter that says what you told
us on the phone.
When you appeal, you must give our plan:
•

Your name

•

Your address or an address where we should send information about your appeal (if you
don’t have a current address, you can still appeal)

•

Your member number with our plan

•

The reason(s) you’re appealing our decision

•

If you want a standard or a fast appeal. (For a fast appeal, tell us why you need one.)

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

•

Anything you want our plan to look at that shows why you need the . For example, you can send
us:
o

Medical records from your ,

o

Letters from your (such as a statement from your
that says why you need a fast appeal), or

o

Other information that says why you need the

To get more information on how to appeal, call Member Services at (TTY: ). You can also find more information in
our plan’s [insert Evidence of Coverage, Member or Enrollee Handbook, or other term plan
uses], [plans may insert chapter and/or section reference, as applicable]. An up-to-date copy of
the [insert Evidence of Coverage, Member or Enrollee Handbook, or other term plan uses] is
always available on our website at or by calling our plan.

[Optional to delete 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

How
to keep getting your during your appeal
authorization of the medical service/item and/or Medicare Part B drug or Medicaid drug:

If you’re already getting the listed on the first page of this letter, you can ask to keep getting it during your appeal.
•

You must appeal and ask our plan to continue getting your by [Insert continuation of benefits
request filing date in month, date, year format. Date will be the later of the following: (1)
10 calendar days from date of letter (or later than 10 calendar days, if required by the
state) or (2) date the decision takes effect. Insert date in bold text].

•

See the “How to appeal” section earlier in this letter for information about how to contact
our plan.

•

If you ask our plan to continue your by [Insert continuation of benefits request filing date], your will stay the same during
your appeal.

•

If your is filing the appeal for you and you want to keep
getting your , then
your must include your written consent.]

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Font color: Auto

Formatted: Font color: Auto

What happens next
After you appeal, our plan will send you an appeal decision letter to tell you if we approve or
deny your appeal. If our plan still denies [Insert if applicable: payment for] the listed on the first page of this
Coverage Decision Letter, the appeal decision letter will tell you what happens next, such as
information about a Medicare Level 2 appeal or how to ask for a Fair Hearing
[Insert if appropriate: (also called a )].

What to do if you need help with your appeal
You can get someone to appeal for you and act on your behalf. You must first name them in
writing as your “representative” by following the steps below. Your representative can be a
relative, friend, lawyer, doctor, health care provider, or someone else you trust.
If you want someone to appeal for you:
•

Call our plan at (TTY: )
to learn how to name that person as your representative. Or, you can visit
https://www.medicare.gov/claims-appeals/file-an-appeal/can-someone-file-an-appealfor-me. [Plans may replace with a plan-specific web address that explains how enrollees
can appoint a representative.]

•

You and your representative must sign and date a statement that says this is what you
want.

•

Mail or fax the signed statement to us at:

•

Keep a copy.

Get help and more information
•

Member Services: Call
(TTY: ), . You can also visit .

•

[If the state uses an Ombudsman or other enrollee support program, insert the following
language, with state-specific information here: : Call (TTY: ). can answer questions if you
have a problem with your appeal. They can also help you understand what to do next.
They aren’t connected with our plan or with any insurance company or health plan. Their
services are free.]

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Font color: Auto

•

: Call (TTY: ). counselors can help you
with Medicare issues, including how to appeal. isn’t
connected with any insurance company or health plan. Their services are free.

•

Medicare: Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week
(TTY users can call 1-877-486-2048). Or, visit Medicare.gov.

•

: Call (TTY: ).

•

Medicare Rights Center: Call 1-800-333-4114, or visit www.medicarerights.org.

•

Eldercare Locator: Call 1-800-677-1116, or visit
www.eldercare.acl.govwww.eldercare.acl.gov to find help in your community.

•

Commented [M1]: Corrected link.

[If applicable, insert other state or local aging/disability resources contact information.]

You can get this document for free in [Insert, as appropriate: or]
other formats, such as large print, braille, or audio. Call . The call is free.
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 https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice, Visit
Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800633-4227) for more information. TTY users can call 1-877-486-2048.

Commented [M2]: Corrected link.

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 0938-1386. This information collection is for the
coverage decision letter issued upon denial, in whole or in part, of an enrollee’s request for an
integrated organization determination and upon discontinuation or reduction of a previously
approved authorization. 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 per 42 CFR §§ 422.631 and 438.210. 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.****CMS Disclosure**** Please do
not send applications, claims, payments, medical records or any documents containing

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Space After: 0 pt, Line spacing: At least 12 pt

sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents,
please contact the CMS Medicare-Medicaid Coordination Office D-SNP Operations
mailbox at [email protected] Sugarman Coats at
[email protected].

Form CMS-10716
xx/xx/xxxx11/30/2025)

OMB Approval 0938-1386 (Expires:

Formatted: Font: (Default) Times New Roman, 12 pt, Bold