Member’s Name
Member’s address
NOTICE OF DENIAL OF MEDICAL COVERAGE
____________________________________________________________
Date:
Member’s Name: Member ID Number:
______________________________________________________________________
We have denied coverage of the following medical services or items that you or your
physician requested:
Admission to _____________________ Swing Bed facility.
The Gundersen Lutheran Health Plan has determined that you are not eligible for
admission to a swing bed facility.
We denied this request because:
Based upon our review of your medical condition, it does not appear that you
meet Senior Preferred guidelines for skilled nursing care in a swing bed
facility.
However, Gundersen Lutheran Health Plan has approved admission to a
Senior Preferred network skilled nursing facility.
Therefore your admission to _______________________ Swing Bed will not be
covered. If you choose to be admitted to the swing bed facility, please be aware that
you will be responsible for all charges incurred beginning on [Date].
If you need help understanding the information in this letter or require language
assistance at no cost to you, please contact our Customer Service Department at (608)
775-8077 or (800) 394-5566.
For people who are deaf, hard of hearing, or speech impaired please call TTY 711, or
you may call through a video relay service company of your choice. A customer service
representative is available to assist you Monday through Friday from 8:00 a.m. to 8:00
p.m. You can also visit our website at www.seniorpreferred.org.
Our Medical Director is available to discuss this decision with your physician upon
request. If you would like a copy of the policy or coverage guidelines used to make this
decision, please call us at (608) 775-8077, (800) 394-5566.
Sincerely,
Gundersen Lutheran Health Plan, Inc.
Form CMS-10003-NDMC (Exp. 10/31/2013) OMB Approval 0938-0829
H5262_10-67A File and Use: 09/11/2011
cc: [SB provider]
Gundersen Lutheran Health Plan Member File
What If I Don’t Agree With This Decision?
You have the right to appeal. 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 your treating physician may file an appeal. Or you may name a relative, friend,
advocate, attorney, doctor (other than your treating physician), or someone else to act
as your representative. Others also already may be authorized under State law to act
for you.
You can call us at: (608) 775-8052 or (800) 897-1923, extension 58052 to learn how to
name your representative.
If you have a hearing or speech impairment, please call us at TTY 711.
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.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE
This is to acknowledge that I received this notice of non-coverage of services from
Gundersen Lutheran Senior Preferred. I understand that my signature below does not
indicate that I agree with the notice, only that I have received a copy of the notice.
_______________________________________________ ____________________________
Signature of Beneficiary Date
(or Person Acting on His/Her Behalf)
Form CMS-10003-NDMC (Exp. 10/31/2013) OMB Approval 0938-0829
H5262_10-67A File and Use: 09/11/2011
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
There Are Two Kinds of Appeals You Can How Do I File An Appeal?
File
Standard (30 days) - You can ask for a For a Standard Appeal: You or your
standard appeal. We must give you a authorized representative should mail or
decision no later than 30 days after we get deliver your written appeal to the address(es)
your appeal. (We may extend this time below:
by up to 14 days if you request an Gundersen Lutheran Health Plan, Inc.
extension, or if we need additional Attn: Member Advocate
information and the extension benefits you.) 1836 South Avenue
Mail Stop NCA2-01
Fast (72 hour review)- You can ask for a La Crosse, Wisconsin 54601
fast appeal if you or your doctor believe
that your health could be seriously harmed Personal deliveries can be brought to
by waiting too long for a decision. Gundersen Lutheran Health Plan, 3190
We must decide on a fast appeal no later Gundersen Drive, Onalaska, Wisconsin.
than 72 hours after we get your appeal.
(We may extend this time by up to 14 days For a Fast Appeal: You or your authorized
if you request an extension, or if we need representative should contact us by telephone
additional information and the extension or fax: By telephone, the numbers are (608)
benefits you.) 775-8052 or (800) 897-1923, ext. 58052 or
TTY: 711. By fax, the number is (608) 775-
If any doctor asks for a fast appeal for
8091, Attn: Member Advocate.
you, or supports you in asking for one,
and the doctor indicates that waiting
What Happens Next? If you appeal, we will
for 30 days could seriously harm your
review our decision. After we review our
health, we will automatically give
decision, if any of the services you requested
you a fast appeal.
are still denied, Medicare will provide you with
If you ask for a fast appeal without a new and impartial review of your case by a
support from a doctor, we will decide reviewer outside of your Medicare Health
if your health requires a fast appeal. Plan. If you disagree with that decision, you
If we do not give you a fast appeal, we will have further appeal rights. You will be
will decide your appeal within 30 days. notified of those appeal rights if this happens.
What Do I Include With My Appeal? Contact Information:
You should include: your name, address, If you need information or help, call us at:
Member ID number, reasons for appealing, (608) 775-8052.
and any evidence you wish to attach. You Toll Free: (800) 897-1923, Ext. 58052
may send in supporting medical records, TTY: 711
doctors' letters, or other information that
explains why we should provide the service. Other Resources To Help You:
Call your doctor if you need this information Medicare Rights Center:
to help you with your appeal. You may send Toll Free: 1-888-HMO-9050
in this information or present this information Elder Care Locator
in person if you wish. Toll Free: 1-800-677-1116
1-800-Medicare (1-800-633-4227)
TTY: 1-877-486-2048
Form CMS-10003-NDMC (Exp. 10/31/2013) OMB Approval 0938-0829
H5262_10-67A File and Use: 09/11/2011