Notice Testing Guide

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html


Notice of Denial of Medical Coverage

Date:									Member number:

Name:



Your request was denied
We’ve denied the medical services/items listed below requested by you or your doctor or provider: 
    • Service A

Why did we deny your request?
We denied the medical services/items listed above because: 
Per Medical Director review of the applicable medical guidelines, we have determined that your request does not meet medical requirements and, therefore, cannot be approved.

Medicare covers services and items that are considered to be reasonable and necessary. Current medical guidelines indicate that this service is considered reasonable and necessary when you meet the folowing requirements:

I. Service A may be indicated by the following:

1. Recent history of symptom 1 and symptom 2

2. Test results are negative or inconclusive

We are not able to approve your request because the notes given to us by your doctor did not document that you are having symptom 1. Only symptom 2 was noted.

Prior to making our decision, we did reach out to your physician. However, based on the clinical information we received, your request is not medically necessary. You may discuss this with your physician.

You should share a copy of this decision with your doctor and discuss next steps. If your doctor asked for coverage on your behalf, we sent them a copy of this decision.

You have the right to appeal our decision
You have the right to ask ABC Health to review our decision by asking us for an appeal.  

Plan Appeal:  Ask ABC Health 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 ABC Health” 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.  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 provider must agree that you should continue getting the service.  If you lose your appeal, you may have to pay for these services.


If you want someone else to act for you
You can name a relative, friend, attorney, doctor, or someone else to act as your representative.  If you want someone else to act for you, call us at: 800-446-4566 to learn how to name your representative.  TTY users call 800-338-6799.  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 ABC Health
Standard Appeal – We’ll give you a written decision on a standard appeal within 30 days after we get your appeal.  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.  If your appeal is for payment of a medical service you already received, we’ll give you a written decision within 60 days.

Fast Appeal – We’ll give you a decision on a fast appeal within 72 hours after we get your appeal.  You can ask for a fast appeal if you or your doctor believe your health could be seriously harmed by waiting up to 30 days for a decision. You can’t ask for an expedited appeal if you’re asking us to pay you back for a medical service you already received. 

We’ll automatically give you a fast appeal if a doctor asks for one for you or if your doctor supports your request.  If you ask for a fast appeal without support from a doctor, we’ll decide if your request requires a fast appeal.  If we don’t give you a fast appeal, we’ll give you a decision within 30 days.  

How to ask for an appeal with ABC Health
Step 1: You, your representative, or your doctor can ask us for an appeal. Your written request must include:

    • Your name
    • Address
    • Member number
    • Reasons for appealing
    • Whether you want a Standard or Fast Appeal (for a Fast Appeal, explain why you need one).
    • Any evidence you want us to review, such as medical records, doctors’ 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.  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 keeping a copy of everything you send us for your records. 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, you can also ask for a copy of the guidelines we used to make our decision.

Step 2: Mail, fax, or deliver your appeal. You can also call us or submit your appeal online.

For a Standard Appeal:  
Mailing Address: ABC Insurance Company, 111 Main Street, Dayton, MD 21036
Phone: 800-446-4566 			TTY Users Call: 800-338-6799                                    
Fax:	223-655-4655			Website: ABCInsuranceCo.com

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: 800-446-4566                     	TTY Users Call: 800-338-6799                
Fax: 223-655-4655		        	Website: ABCInsuranceCo.com 

What happens next?
If you ask for an appeal and we continue to deny your request for medical services, 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.


		




Get help & more information	
    • ABC Insurance Company Toll Free:	800-335-3455 TTY users call: 800-227-5688
Monday-Friday 8:00 AM EST – 4:30 PM EST
ABCInsuranceCo.com
    • 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 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: 877-839-2675




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 0938-1382 GenIC #10. This information collection is being conducted to help improve informational notices for people with Medicare and the results will be used to ensure that people with Medicare understand important information about their plans. The time required to complete this information collection is estimated to average less than 60 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 voluntary and CMS will keep the information private to the extent provided by law. 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. 

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