OMB Approval 0938-0829 NOTICE OF DENIAL OF PAYMENT Date: Member ID Number: Beneficiary’s name: We,________________________________________________________________________, recently received a claim for: _____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ provided to you by __________________________________________on ________________. ____________________________________________________________________________ We will not pay for _____________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________. because:_____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ CMS Form 10003-NDP American LegalNet, Inc. www.FormsWorkflow.com OMB Approval 0938-0829 IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS For more information about your appeal rights, call us or see your Evidence of Coverage. What If I Don’t Agree With This Decision? You have the right to appeal. To exercise it, file your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline. Who May File An Appeal? You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you. You can call us at: (___)_______ to learn how to name your authorized representative. [If you have a hearing or speech impairment, please call us at TTY/TTD (___)__________]. If you want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person to act for you. How Do I File An Appeal? You or your authorized representative should mail or deliver your written appeal to the address(es) below: We must give you a decision no later than 60 calendar days after we receive your appeal. Form No. CMS-10003 What Do I Include With My Appeal? You should include: your name, address, Member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors’ letters, or other information that explains why we should pay for the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish. What Happens Next? If you appeal, we will review our decision. After we review our decision, if payment for any of your claims is still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare Health Plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. Contact Information: If you need information or help, call us at: Toll Free: TTY: Other Resources To Help You: Medicare Rights Center Toll Free: 1-888-HMO-9050 Elder Care Locator Toll Free: 1-800-677-1116 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048 Exp. Date 8/31/2010 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 information collection is 0938-0829. The time required to complete this information collection is estimated to average 6.3 to 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.FormsWorkflow.com