Crosswalk

EXHIBIT A

Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP
CHANGE CROSSWALK
CURRENTLY
APPROVED

On Page 1 under section
Why did we deny your
request?
On Page 2 under section
How to ask for an appeal
with {health plan name}
Step 1:
On Page 3 under section
“What happens next?”
The “Fast Appeal” section
reads:
We’ll give you a decision
on a fast appeal within
{insert appropriate
timeframe for medical
service/item or Part B or
Medicaid drug: 72 hours,
24 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 cannot request an
expedited appeal if you
are asking us to pay you
back for a {medical
service/item or Part B
drug} you’ve already
received.
We’ll automatically give
you a fast appeal if a
doctor asks for one for
you or if your doctor

CHANGE TO NOTICE

EXPLANATION

Changed all terms that
stated, “Part B or Medicaid
drug” to “Part B drug or
Medicaid drug”.

This text was erroneously
removed from the notice
and is being reinserted to
clarify that plans should
enter the term “Part B
drug” and not “Part B”,
when applicable.

Bracketed text related to
Part B drug timeframes
has been reinserted in
both paragraphs of this
section to read:
We’ll give you a
decision on a fast
appeal within 72 hours
[Insert timeframe for
expedited internal plan
Medicaid appeals, if
different] 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
{insert appropriate
timeframe for medical
service/item or Part B
drug: 30 days, 7 days}
for a decision. You
cannot request an
expedited appeal if you
are asking us to pay you
back for a {medical
service/item or Part B

This bracketed text was
erroneously removed from
the notice and is being
reinserted for accuracy
and to account for Part B
drug timeframes.

CURRENTLY
APPROVED

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.

On page 2, under section
“How to ask for an
appeal with {health plan
name}”: If you’re asking
for an appeal and missed
the deadline, you may
include your reason for
being late.
On page 3 under section
“How to ask for an
appeal with {health plan
name}”:
For a Standard Appeal:
Mailing Address: {In
Person Delivery Address:}
{Phone:}
{TTY Users Call:}
Fax:
On page 3, under section
“What happens next?”
If you ask for an appeal,
we will send you another
letter with a decision to tell
you if we approve or deny

CHANGE TO NOTICE

EXPLANATION

drug} you’ve 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
{insert appropriate
timeframe for medical
service/item or Part B
drug: 30 days, 7 days}.
If you’re asking for an
appeal and missed the
deadline, you may request
an extension and should
include your reason for
being late.

This text was erroneously
removed from the notice
and is being reinserted to
specify an enrollee may
ask for a good cause
extension.

“How to ask for an
appeal with {health plan
name}”:
For a Standard Appeal:
Mailing Address: {In
Person Delivery Address:}
{Phone:}
{TTY Users Call:}
Fax:

Restored curly brackets
around “Phone” under
standard appeals. Plans
are not required to accept
verbal requests for appeals
and curly brackets provide
plans the option to add a
phone number.

“What happens next?”

Removed language
regarding enrollees
receiving a decision letter
because plans are not
required to send
notification to an enrollee if

‘If you ask for an appeal
and we continue to deny
your request for {payment
of} a {medical service/item

CURRENTLY
APPROVED

your request. If we
continue to deny your
request for {payment of} a
{medical service/item or
Part B or Medicaid drug},
we’ll send you a written
decision and automatically
send your case to an
independent reviewer.

CHANGE TO NOTICE

EXPLANATION

or Part B drug or Medicaid
drug, we’ll automatically
send your case to an
independent reviewer.

a denial is upheld and their
case is forwarded to the
IRE.