Instructions CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Pay...

Form Instructions for the Notice of Denial of Medical Coverage (or
Payment) CMS-10003-NDMCP
A Medicare health plan (“plan”) must complete and issue this notice to enrollees when it
denies, in whole or in part, a request for a medical service/item, Part B or Medicaid drug
or a request for payment of a medical service/item or Part B or Medicaid drug the
enrollee has already received. The notice contains text in curly brackets “{ }” to be
inserted, as applicable, as explained in these instructions. The notice also contains text
in square brackets “[ ]” that is to be inserted, as applicable, if a plan enrollee receives
full benefits under a State Medical Assistance (Medicaid) program and the plan denies a
medical service/item or Part B or Medicaid drug that is subject to Medicaid appeal rights.
Bracketed text shown in italics must be inserted in the notice as written when the
language applies under state Medicaid rules. Bracketed text that is not italicized
provides instruction on text to be inserted in the notice.
The OMB control number must be displayed on the notice. The notice must be
provided in 12 point font.
When the Spanish-language version of this notice is used, the Medicare health plan
must make insertions on the notice in Spanish. Additional steps need to be taken to
ensure that the enrollee comprehends the content of the notice.

Heading
• Date: Insert the month, day, and year the notice is issued.
• Name: Insert the enrollee’s full name.
• Member number: Insert the enrollee’s plan identification number.
A plan is permitted to insert additional fields of information in the header section of the
notice consistent with applicable State requirements, such as the enrollee’s Medicaid
number, provider name, and date of service.

Section Titled: Your request was {Insert appropriate term: partially approved,
denied}
The plan must insert the appropriate term in the title and body of this section to describe
the action taken; that is, whether the service was denied, partially approved, stopped,
reduced or, in the case of a Medicaid service, suspended (temporarily stopping a
service). If the denial involves a payment request, the plan must insert the payment of
text shown in brackets. In the free text field, the plan must clearly and specifically list
the denied medical services/items or Part B or Medicaid drugs. For stopped, reduced or
suspended services, include the date the decision will take effect.

Section Titled: Why did we deny your request?
The plan must insert the appropriate term to describe the action taken; that is, whether
the service was denied, partially approved, stopped, reduced or, in the case of a
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: xx/xx/xxxx)

Medicaid service, suspended (temporarily stopping a service). In the free text field, the
plan must provide a specific and detailed explanation of why the medical services/items
or Part B or Medicaid drugs were denied, including a description of the applicable
Medicare (or Medicaid) coverage rule or applicable plan policy (e.g., Evidence of
Coverage provision) upon which the action was based. A specific explanation about
what information is needed to approve coverage must be included.
Plans that provide both Medicare and Medicaid benefits1 (e.g., integrated Dual Special
Needs Plans) should determine if the request for payment or coverage concerns a
medical service/item or Part B or Medicaid drug covered under the plan’s Medicare or
Medicaid benefits. Plans can make such determinations based on consideration of the
following criteria:
•
•
•

The medical service/item or Part B or Medicaid drug is identified in plan materials,
such as the Evidence of Coverage (Enrollee Handbook), as solely a Medicaid
benefit;
The medical service/item or Part B or Medicaid drug was previously approved
solely under the plan’s Medicaid benefits, and the request is for reauthorization or
payment for services following such approval (see below for more discussion);
The service is only covered under the plan’s Medicaid benefits and never covered
by Medicare and not covered by the MA plan as a supplemental Medicare benefit
(Medicaid-only services are generally limited to non-medical services such as
Medicaid home- and community-based long term services and supports that the
plan is contracted to provide to eligible Medicaid beneficiaries, such as personal
care attendants. Integrated plans should work with their states to develop a
definitive list of these Medicaid-only services.).

If the request is classified by the plan as a request for payment or coverage under the
plan’s Medicaid benefits that is fully covered under the plan’s Medicaid benefits the IDN
should not be sent. If the request is classified as a request for only Medicaid coverage,
and the plan denies coverage or payment in whole or in part under the plan’s Medicaid
benefits, then the plan should send any notices required to meet state Medicaid notice
requirements.
When an integrated D-SNP receives a request for payment or coverage that cannot be
readily classified falling solely under the plan’s Medicaid benefits (e.g., the request is for a
service with overlapping Medicare and Medicaid coverage, such as home health services,
or the request is not specific enough to classify, such as a request for a home health
aide), and the plan determines the service/item or Part B or Medicaid drug is not covered
under the plan’s Medicare benefits, but is fully covered under the plan’s Medicaid
benefits, then the plan must send a notice informing the plan enrollee of the denial of
Medicare coverage and the relevant Medicare appeal rights. Further, in situations where
there is any chance of Medicare coverage, but the plan provides coverage only under the
Effective January 2021, other plans that provide both Medicare and Medicaid benefits that are “applicable
integrated plans” under 42 C.F.R. § 422.561 should follow the notice requirements for integrated organization
determinations and reconsiderations under 42 C.F.R. §§ 422.629 through 422.634.

1

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: xx/xx/xxxx)

Medicaid benefit, the plan must send a notice informing the plan enrollee of the denial of
Medicare coverage and the relevant Medicare appeal rights. The plan must use the IDN
to fulfill this requirement and use the free text field to explain that the service/item or Part
B or Medicaid drug will be covered under the enrollee’s Medicaid benefits (in addition to
the required explanation related to the Medicare denial). For example, the free text field
could include the following: “Medicare doesn’t cover (insert medical service) because
(insert detailed rationale). However, since we manage both your Medicare and Medicaid
health benefits, we have determined that the service can be covered under your Medicaid
benefits and we have authorized coverage for you to receive (insert medical service).”
Section Titled: You have the right to appeal our decision
The plan must insert its name in the {health plan name} field.
If the action taken involves Medicaid benefits, insert text shown in the square brackets, as
applicable. If the enrollee is not required to exhaust the plan level appeal before
requesting a State Fair Hearing, the notice must inform the enrollee of the right to
concurrently request a plan appeal and a State Fair Hearing. The plan must insert
applicable timeframes for requesting a State Fair Hearing.

Section Titled: If you want someone else to act for you
The plan must insert the phone and TTY numbers to be used if the enrollee needs
information on how to name a representative.

Section Titled: There are 2 kinds of appeals with {health plan name}
In the title to this section, insert the health plan name.
Standard Appeal - As applicable, the plan must insert the appropriate adjudication
timeframe for Medicare medical services/items or Part B drugs, or standard Medicaid
appeals.
Fast Appeal - As applicable, the plan must insert the appropriate adjudication
timeframe for medical services/items or Part B or Medicaid drugs.

Section Titled: How to ask for an appeal with {health plan name}
In the title to this section, insert the health plan name.
Step 1: If the plan requires the appeal to be in writing, insert the bracketed option of
written. If the notice relates to a Medicaid service, insert the italicized text shown in
the square brackets.
Step 2: In the spaces provided for Standard and Fast Appeals, the plan must insert the
plan's address, phone and fax number(s). If the plan accepts standard appeal requests
by phone and/or electronically, insert the text shown in brackets.
Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: xx/xx/xxxx)

Section Titled: What happens next?
If the denial involves a payment request, insert the payment of text shown in brackets. If
the notice relates to Medicaid services, insert additional State-specific rules, as
applicable.

Section Titled: How to ask for a Medicaid State Fair Hearing?
The optional Medicaid text in brackets must be included if the plan manages both
Medicare and Medicaid benefits and the service/item or Part B or Medicaid drug is subject
to Medicaid appeal rights. If applicable, insert text shown in square brackets if a Medicaid
service was denied, partially approved, stopped, reduced, or suspended. The plan must
insert applicable timeframes for State Fair Hearings, as well as address, phone and fax
numbers. If the denied medical services/items do not involve Medicaid services, the text
related to asking for a State Fair Hearing must not be included in the notice.

Section Titled: Get help & more information
In the spaces provided, the plan must insert the plan’s toll free phone and TTY numbers
for the enrollee, physician or representative to call if they need information or help. This
section must always be included in the notice, whether or not the notice integrates the
text from the preceding section containing bracketed language related to Medicaid State
Fair Hearings. If the notice involves a Medicaid service, the plan must insert
Medicaid/State contact information. If applicable, the plan should insert state/local
disability and aging services contact information.

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
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.

Form CMS 10003-NDMCP

OMB Approval 0938-0829 (Expires: xx/xx/xxxx)