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Notices and Forms

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 “Medicare Managed Care Appeals & Grievances” link on the left-hand side of this page or the links in the "Downloads" and the "Related Links" sections below.

Standardized Notices and Forms

A CMS Form number and 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, 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:

  • Integrated Denial Notice (IDN) Form CMS-10003-NDMCP

The IDN combines and replaces the standardized Medicare Part C denial notices entitled "Notice of Denial of Payment" and "Notice of Denial of Medical Coverage" (Form CMS-10003-NDP and Form CMS-10003-NDMC, respectively). 

To view the Integrated Denial Notice, click on the "MA Denial Notices" link in the "Related Links" section below. 

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.

To view the Notice of Medicare Non-Coverage or Detailed Explanation of Non-Coverage, click on the "MA ED Notices" link in the "Related Links" section below.

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).

To view the Appointment of Representative Form, click on the "Appointment of Representative Form CMS-1696" link 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 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.

To view the Important Message From Medicare or Detailed Notice of Discharge, click on the “Hospital Discharge Appeal Notices” link in the "Related Links" section below.

Data Form

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

To view the Appeal and Grievance Data Form and its corresponding instructions, click on the "Appeal and Grievance Data Form" links in the "Downloads" section below. 

Model Notices

CMS model notices contain all of the elements CMS requires for proper notification to enrollees or non-contract providers, if applicable. Providers and plans may modify the model notices and submit them to the appropriate CMS regional office for review and approval.

The following model notices are contained in the appendices to Chapter 13 of the Medicare Managed Care Manual and may be viewed by clicking on the links in the "Downloads" section below:

  • Notice of Right to an Expedited Grievance – Appendix 6
  • Waiver of Liability Statement – Appendix 7
  • Notice of Appeal Status – Appendix 10
  • Notice of Dismissal of Appeal -NEW NOTICE (to be incorporated in future Chapter 13 update)

October 2013 - IMPORTANT UPDATE:

ISSUANCE OF NEW MODEL DISMISSAL NOTICE

Effective January 1, 2014: Medicare Advantage (MA) organizations and other Medicare health plans (collectively referred to as "plans") will be responsible for dismissing reconsideration requests when appropriate.  Upon dismissal, plans must provide timely notification of dismissal, informing enrollees and other parties about their right to request IRE review of the plan's dismissal.  To facilitate proper notice of a plan's decision to dismiss a reconsideration request, CMS has developed a model Notice of Dismissal of Appeal Request.  A copy of the Notice of Dismissal of Appeal Request may be viewed by clicking on the link in the "Downloads" section below.

Please refer to the September 10, 2013 and October 30, 2013 HPMS memos entitled, "Change in Part C Reconsideration Dismissal Procedures," and Chapter 13 of the Medicare Managed Care Manual for additional details.

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