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					                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **




Medicare Advantage (MA) Organization Determination Notices
           Title                                                                               Description & Use

Notice of                        Advanced written notice to inform the member admitted to an acute med-surg, mental health or rehab facility that
Discharge &                      covered hospital care is ending.
Medicare Appeal
                                 Provided when:
Rights (NODMAR)
                                       Member does not agree with the discharge
H2229-2005-1
                                         MA plan is not discharging the member, but no longer intends to continue coverage

                                 Delivered by the case manager to the member/authorized representative for their signature, signed
                                 acknowledgement, no later than 6 pm of the day before coverage ends. (Note: Member is entitled to coverage
                                 until noon of the calendar day following the day MassPRO notifies the member of its official Medicare coverage
                                 decision.)

                                 Notice must include:
                                       Member’s appeal rights
                                         Specific reason why inpatient hospital care is no longer needed
                                         Anticipated effective date of member’s financial liability for continued inpatient care
                                         Alternative care options




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
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                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **



Medicare Advantage (MA) Organization Determination Notices (continued)

           Title                                                                               Description & Use

Notice of Denial                 Pre-Service written notice to inform the member of a denied request for medical service.
of Medical
Coverage (NDMC)                  Provided when:
                                       Member requests future services and/or equipment
H2229-2005-3
                                         Member believes services should continue (including SNF EOB)
*OMB approval No.
0938-0829
                                         Medical Group has verbally informed member of their denial coverage decision
                                         Standard Requests: Medical Group submits a completed ‘Expedited Organization Determination
*Form No. CMS-10003-
NDMC
                                         Approvals & NDMC Form’ to Tufts Medicare Preferred Appeals & Grievances
                                                Within 10 calendar days for a standard request
(June 2001)
                                         Expedited Requests: Medical Group informs Tufts Medicare Preferred Appeals & Grievances of their
                                         decision to approve or deny, and submits a completed ‘Expedited Organization Determination Approval &
                                         NDMC Form’
Expedited                                       Within 24 hours for an expedited request
Organization
Determination                    Delivered by MA Plan to the member/authorized representative by mail:
Approval & Notice                      At or before the time of noncoverage
of Denial of                           Member must be notified in writing as expeditiously as their health condition requires, but no later than
Medical Coverage                       14 calendar days (standard) or 72 hours (expedited) from the date/time of the request, unless an
Request Form                           extension is justified (note: see Extension notices)

Implemented (July1, 2004)        Notice must include:
                                       Signature of the Medical Director
Expedited                                     On the NDMC template for MHSA & CR
Organization                                  On the EODA & NDMC Request Form for A&G
Determination                          Member’s appeal rights
Approval & Notice                        Date of the last covered day must be clearly stated, if applicable
of Denial of
                                         Specific and detailed explanation why the medical service or items are being denied
Medical Coverage
Request Form                             Description of any applicable Medicare Coverage rule or any other applicable MA plan organization policy
Explanation of                           upon which the denial decision was based. Resources include:
Form Fields                                     Medicare Coverage Issues Manual @ http://www.cms.hhs.gov/manuals/cmstoc.asp
                                                Medicare Intermediary Manual, Addendum A: section 3722.1 for SNF rationale codes
                                                MA plan benefit documents (Evidence of Coverage, Summary of Benefits)

                                 Notice used in situations such as:
                                       SNF exhaustion of benefits when member disagrees;
                                         Acute Rehab or SNF admission denials;
                                         Service requests to visit an out-of-plan/non-contracted specialist when there is a comparable
                                         in-plan/contracted specialist
                                         Requests to rent or purchase durable medical equipment (DME) in a SNF;
                                         Homecare services when the Medical Group determines that the member does not meet the CMS criteria




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
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                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **



Medicare Advantage (MA) Organization Determination Notices (continued)

           Title                                                                               Description & Use

Notice of                        Advanced written notice to inform the member, who is receiving services from a Skilled Nursing Facility (SNF),
Medicare Non-                    Home Care Agency (HCA), or Comprehensive Outpatient Rehab Facility (CORF), covered care is ending.
Coverage
                                 Provided when:
(NOMNC)
                                       Physician has determined the member no longer meets the SNF/CORF or HCA criteria for coverage at a
                                       skilled level of care
NOMNC                                    Member agrees or disagrees with the discharge plan
Instructions
                                 Delivered by the SNF/CORF/HCA provider to the member/authorized representative or mailed to the member’s
                                 authorized representative. Notification is minimally:
*OMB Approval                          Two (2) days prior to the last covered day for SNF/CORF
No. 0938-0910
                                         Next to the last visit for HCA services
Exp date 3/31/2007

CMS-10095-A                      Notice must include:
                                       Signature of member/authorized representative, or
                                              If the member refuses to sign, the refusal should be witnessed on the signature page and filed, a
                                              copy should be provided to the member
                                              If member is unable to sign, verbal notification is considered “valid” when documentation in the
                                              medical record of the date & time of the telephone call to the authorized representative explaining
                                              the contents of the NOMNC and appeal rights is completed
                                       Type of services ending
                                         Effective date services will end
                                         Description of the member’s right to a Fast-Track appeal & other MA plan appeal procedures
                                         Member’s right to receive detailed information to explain the NOMNC


Detailed                         Written notice to provide the specific clinical rational for the SNF/HCA/CORF termination or reduction of
Explanation of                   skilled services.
Non-Coverage
                                 Provided when the Independent Review Entity (IRE) accepts the member request for a Fast-Track Appeal.
(DENC)                           (Note: Although the MA Plan should provide the enrollee [and the IRE] with a DENC as soon as it learns of the
                                 appeal request, it may be appropriate to delay providing the enrollee’s medical records until shortly before the
                                 planned coverage termination, when the record is presumably complete enough to permit an informed IRE
DENC                             determination.)
Instructions
                                 Delivered by the MA Plan to the member and the IRE by mail, minimally, before covered services end.
*OMB Approval
No. 0938-0910
                                 Notice must include:
Exp date 3/31/2007                     Type of Service denied
CMS-10095-B                              Relevant facts to make the determination
                                         Description of any applicable Medicare Coverage rule or any other applicable MA plan organization policy
                                         upon which the denial decision was based. Resources include:
                                                Medicare Coverage Issues Manual @ http://www.cms.hhs.gov/manuals/cmstoc.asp
                                                Medicare Intermediary Manual, Addendum A: section 3722.1 for SNF rationale codes
                                                MA plan benefit documents (Evidence of Coverage, Summary of Benefits)




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
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                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **



Medicare Advantage (MA) Organization Determination Notices (continued)

           Title                                                                               Description & Use

MA                               Written letter to explain why denied SNF, Hospital, CORF or Home Care services are being reinstated.
Reinstatement of
Skilled Services                 Provided when prospective, concurrent, or retrospective review of the medical record reveals:
Letter                                 Coverage of skilled care is/was medically necessary
                                         Required notification timeframe(s) not met

MA                               Delivered by the Medical Group or MA Plan to the member by mail.
Reinstatement of
Skilled Services                 Letter must include:
Letter                                  Effective date of reinstatement
Addendums                                Date of original denial notice
                                         Reason for reinstatement from the Addendum list
H2229-2005-004
                                         Who to contact with questions


Notice of Denial                 Post-Service written notice to inform the member of a denial of payment for services already rendered.
of Payment (NDP)
                                 Provided when:
*OMB Approval No.                      Member is ineligible for coverage
0938-0829
                                         Service is not a covered benefit
*Form No. CMS-10003-
NDP (June 2001)                          Claim is received by the MA plan or Medical Group and no PCP prior approval/referral was obtained
                                         [Note: To submit a post-service denial (a denied referral) the Medical Group enters the word ‘deny’ on the
                                         Claims Discrepancy or 10-Day Report.]

                                 Delivered by MA Plan/Tufts Medicare Preferred Claims to the member by mail.

                                 Notice must include:
                                       Member’s appeal rights
                                         Specific and detailed explanation why medical service rendered or items provided are denied
                                         Description of any applicable Medicare coverage rule or any other applicable MA plan organization policy
                                         upon which the claim decision was based. Resources include:
                                                Medicare Coverage Issues Manual @ http://www.cms.hhs.gov/manuals/cmstoc.asp
                                                Medicare Intermediary Manual, Addendum A: section 3722.1 for SNF rationale codes
                                                MA plan benefit documents (Evidence of Coverage, Summary of Benefits)

                                 Notice used in situations such as:
                                       Requests for payment for non-emergent, non-urgent services that the member received without obtaining
                                       PCP prior approval/referral
                                         Rented or purchased DME when the member was in a SNF
                                         Member termed from MA plan on the date of service




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
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                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **



Medicare Advantage (MA) Organization Determination Notices (continued)

           Title                                                                               Description & Use

Written Follow-Up                Written notice, when justified, to request an extension of up to 14 calendar days to make a standard (non-
Notice: Extension                urgent) initial organization determination when additional information is needed.
needed - Standard
                                 Provided when justification can be demonstrated by:
Standard Organization                  Decision delay is in the interest of the member
Determination Extension
Letter                                   Member requests extension
H2229-2005-049
                                         Need exists for additional information, diagnostic tests or medical evidence from a non-contracted provider

                                 Delivered by MA Plan/A&G to the member by mail.

                                 Extension must include:
                                      Reason for the delay
                                         Time allotted to obtain additional information
                                         Information about the member & MA plan responsibilities during the extension period
                                         Member appeal & grievance rights

                                 Notice is used in a situation such as:
                                       A request for a second opinion
                                         A request for additional diagnostic testing


Written Follow-Up                Written notice, when justified, to request an extension of up to 72 hours to make an expedited (urgent) initial
Notice: Extension                organization determination when additional information is needed.
needed - Expedited
                                 Provided when justification can be demonstrated by:
Expedited Organization                 Decision delay is in the interest of the member
Determination Extension
Letter                                   Member requests extension
H2229-2005-019
                                         Need exists for additional information, diagnostic tests or medical evidence from a non-contracted provider

                                 Delivered by MA Plan/A&G to the member by mail.

                                 Extension must include:
                                      Reason for the delay
                                         Time allotted to obtain additional information
                                         Information about the member & MA plan responsibilities during the extension period
                                         Member grievance rights

                                 Notice is used in a situation such as when needed information from an out-of-plan provider is not complete or
                                 received within the allowed timeframe to decide upon a member’s request for coverage of an experimental
                                 cancer treatment procedure.




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
                                                                                     Page 5 of 6
                   TUFTS HEALTH PLAN MEDICARE PREFERRED PPO NOTICE & LETTER TEMPLATES * **



Medicare Advantage (MA) Organization Determination Notices (continued)

           Title                                                                               Description & Use

Written Follow Up                Written notice to inform the member, based on the information available, their expedited request did not meet
Notice: Did not                  Medicare’s definition of “time sensitive” and thus will be processed through the standard appeals process.
meet Criteria
                                 Provided when the extension for additional information will not be processed through the expedited appeals
Not Expedited Appeal             process.
Criteria Letter
H2229-2005-038                   Delivered by MA Plan/A&G to the member by mail.

                                 Notice must include:
                                       Member’s grievance rights
                                         Medicare’s definition of “time sensitive”

                                 Note: Medicare definition of “Time sensitive” is a situation where the time frame of the standard decision
                                 process could jeopardize the life or health of the member, or could jeopardize the member’s ability to regain
                                 maximum function.




*OMB or CMS Form control number must be displayed on the notice. Tufts Health Plan Medicare Preferred PPO notice templates are available on the Tufts Health Plan internal & external
internets. More specific information concerning organization determinations is available at the following Medicare website: http://www.cms.hhs.gov/manuals/116_mmc/mc86c05.pdf

**For specific turnaround timeframes for written & verbal notification requirements, reference the ‘Utilization Review Determination Timeframes for Tufts Health Plan Medicare Preferred
PPO Members’ & the ‘Initial Organization Determination Category Examples’ grids.

DMS 1079930
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