Notices and Forms
Medicare health plans must meet the notification requirements for grievances, organization determinations, and appeals processing under the Medicare Advantage regulations found at 42 CFR 422, Subpart M.
Details on the applicable notices and forms are available below (including English and Spanish versions of the standardized notices and forms).
Standardized Notices and Forms
A CMS Form number and Office of Management and Budget (OMB) approval number, which must appear on the notice, identify OMB-approved, standardized notices and forms. CMS has developed standardized notices and forms for use by plans, providers and enrollees as described below:
Notice of Denial for Payment or Services
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. The notice used for this purpose is the:
- Notice of Denial of Medical Coverage or Payment (NDMCP), Form CMS-10003-NDMCP, also known as the Integrated Denial Notice (IDN)
This form and its instructions can be accessed on the "MA Denial Notices" webpage at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MADenialNotices.html
Notice of Termination of Services (SNF, HHA, CORF)
A provider must issue advance written notice to enrollees 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) Form CMS-10123-NOMNC, and the
- Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC.
These forms and their instructions can be accessed on the "MA Expedited Determination Notices" webpage at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MAEDNotices.html
Appointment of Representative
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).
A link to this form is in the "Related Links" section below.
Hospital Discharge Notices
As 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 Quality Improvement Organization (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) Form CMS-R-193, and the
- Detailed Notice of Discharge (DND) Form CMS-10066.
These forms and their instructions can be accessed on the webpage “Hospital Discharge Appeal Notices” at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html
Medicare Outpatient Observation Notice (MOON)
Hospitals and CAHs are required to provide a MOON to Medicare beneficiaries (including Medicare Advantage health plan enrollees) informing them that they are outpatients receiving observation services and are not inpatients of a hospital or critical access hospital (CAH).
This form and its instructions can be accessed on the webpage "Medicare Outpatient Observation Notice (MOON)" at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON.html
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, Form CMS-R-0282
A link to this form is in the "Downloads" section below.Request for Administrative Law Judge (ALJ) Hearing
Any party to the reconsideration issued by the Independent Review Entity may use the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100” to request an ALJ hearing.
The direct link to the form “OMHA-100”:
Attorney Adjudicator Review in Lieu of ALJ Hearing
In order to have an attorney adjudicator review the administrative record, in lieu of attending an ALJ hearing, appellants may fill out the “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104) and submit it with your request for a hearing. The direct link to form “OMHA-104”: https://www.hhs.gov/sites/default/files/OMHA-104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf
CMS model notices contain all of the elements CMS requires for proper notification to enrollees or non-contract providers, if applicable. Plans may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plans may use these notices at their discretion.
February 2019: Model notices have been updated with minor changes (e.g., formatting or restructuring for clarity), to align with the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, released February 2019.
The following model notices are available in both Microsoft Word and PDF formats in the "Downloads" section below:
- Notice of Right to an Expedited Grievance
- Waiver of Liability Statement
- Notice of Appeal Status
- Notice of Dismissal of Appeal
- Appeal and Grievance Data Form [PDF, 59KB]
- Appeal and Grievance Data Form Instructions [PDF, 70KB]
- Model Notice of Right to Expedited Grievance_Part C_Feb2019v508 [ZIP, 24KB]
- Model Notice of Appeal Status_Feb2019v508 [ZIP, 19KB]
- Model Notice of Dismissal of Appeal Request_Feb2019v508 [ZIP, 38KB]
- Model Waiver of Liability_Feb2019v508 [ZIP, 18KB]
- Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance [PDF, 647KB]
- Page last Modified: 03/07/2019 1:46 PM
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