Applicable Integrated Plan Coverage Decision Letter (CMS-10716)

This information collection request is for the “Applicable Integrated Plan Coverage Decision Letter” or the “coverage decision letter” will be issued as a result of an integrated organization determination under 42 CFR 422.631, when an applicable integrated plan reduces, stops, suspends, or denies, in whole or in part, a request for a service/item (including a Part B drug) or a request for payment of a service/item (including a Part B drug) the member has already received. “Applicable integrated plans” are defined at 42 CFR 422.561 as full integrated dual special needs plans (FIDE SNPs) and highly integrated dual special needs plans (HIDE SNPs) with exclusively aligned enrollment, where state policy limits the D-SNP’s membership to a Medicaid managed care plan offered by the same organization. These plans will issue the coverage decision letter starting in CY 2021 in place of the Notice of Denial of Medical Coverage (or Payment) (NDMCP) form (CMS-10003) as part of requirements to unify appeals and grievance processes.

The latest form for Applicable Integrated Plan Coverage Decision Letter (CMS-10716) expires 2028-12-31 and is listed under ICR 202507-0938-022.