Medicare Health Plans, which include Medicare Advantage (MA) plans -- such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-For-Service (PFFS) Plans, and Medicare Savings Plans (MSAs) -- Cost Plans, and Health Care Prepayment Plans (HCPPs) must meet the notification requirements for grievances and appeals processing under Subpart M of the Medicare Advantage regulations. 

To view the notices and forms applicable to Part C grievances, organization determinations, and appeals (including Spanish versions of the standardized notices and forms), click on the "Overview" link on the left-hand side of this page and on the links in the "Downloads" section below.

Standardized Notices and Forms

A CMS Form number, OMB approval number, and an OMB disclosure statement, which must appear on the notice, identify OMB-approved, standardized notices and forms.

CMS has developed the following standardized notices and forms for use by plans:

A plan must issue a written notice to an enrollee, an enrollee's representative, or an enrollee's physician when it denies a request for payment or services and the enrollee believes that services should be covered. The notices used for this purpose are the:

• Notice of Denial of Medical Coverage (NDMC), and the
• Notice of Denial of Payment (NDP).

A provider must issue advance written notice to enrollees no later than two calendar days before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end. The two notices used for this purpose are:

• Notice of Medicare Non-Coverage (NOMNC), and the
• Detailed Explanation of Non-Coverage (DENC).

Upon a beneficiary's request, a health plan must provide reports that describe what happened to formal grievance and appeal data. This information must be calculated according to a standardized formula. The form used to report this information to the beneficiary is the:

• Appeal and Grievance Data Form.

If an enrollee would like to appoint a person to file a grievance, request an organization determination, or request an appeal on his or her behalf, the following form may be used:

• Appointment of Representative Form CMS 1696 (AOR).

Like under original Medicare, a hospital must issue to plan enrollees, within two days of admission, a notice describing their rights in an inpatient hospital setting, including the right to an expedited QIO review at their discharge. (In most cases, a hospital also issues a follow-up copy of this notice a day or two before discharge.) If an enrollee files an appeal, then the plan must deliver a detailed notice stating why services should end. The two notices used for this purpose are:

• An Important Message From Medicare About Your Rights (IM), and the
• Detailed Notice of Discharge (DND).

To view the Important Message From Medicare or Detailed Notice of Discharge, click on the "Important Message from Medicare (IM)" link in the "Related Links Inside CMS" section below.

Model Notices

CMS model notices contain all of the elements CMS requires for proper notification to enrollees. Providers and plans may modify the model notices and submit them to their regional offices for review and approval.

The following model notices are contained in the appendices to Chapter 13 of the Medicare Managed Care Manual:

• Notice of Right to an Expedited Grievance – Appendix 5
• Notice of Appeal Status – Appendix 10

To view the model notices mentioned above, click on the links in the "Downloads" section below.

Downloads
Chapter 13 - Medicare Managed Care Manual [PDF, 764KB] Appeal and Grievance Data Form - [PDF, 24KB] Appeal and Grievance Data Form Instructions - [PDF, 40KB] Appointment of Representative Form CMS-1696 - [PDF, 120KB] Notice of Right to an Expedited Grievance – Appendix 5 - [PDF, 64KB] Notice of Appeal Status – Appendix 10  - [PDF, 48KB] Notice of Denial of Medical Coverage (NDMC) in Spanish [PDF, 102KB] Notice of Denial of Payment in Spanish [PDF, 92KB] Notice of Medicare Non-Coverage (NOMNC) in Spanish [PDF, 23KB] Detailed Explanation of Non-Coverage (DENC) in Spanish [PDF, 25KB]
Related Links Inside CMS
Important Message from Medicare (IM)
Related Links Outside CMS
There are no Related Links Outside CMS

Page Last Modified: 06/17/2009 6:27:45 PM
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