Centers for Medicare & Medicaid Services Notice of Denial of Medical Coverage CMS-10003-NDMCP

The term "FMOLHS web sites" refers to the FMOLHS web site and the web sites of all of the aforementioned sponsored organizations and their subsidiaries, including healthesteem.org, and any other sponsored organizations, whether named or unnamed. 

FMOLHS and its sponsored organizations urge that you NOT send confidential or proprietary information through our web sites.

 

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Contact them to report: 

Mail fraud - File an online mail fraud complaint.

Mail Fraud Complaint

Your Information Company Name: * First Name: First Name is required. * Last Name: Last Name is required. * Address: Address is required. * City: City is required. * State: State is required. * ZIP Code: Zip code is required. * Country: Country is required. Cell Phone: Work Phone: Home Phone: Fax: Email Address: Invalid email address.. Age Range: Are you a Veteran?: Yes No Complaint Filed Against Company Name: First Name: Last Name: Address: City: State: ZIP Code: Country: Cell Phone: Work Phone: Home Phone: Fax: Email Address: Invalid email address.. Website Address: How Were You Contacted? How were you contacted? On what date were you contacted? Do you have the envelope it was mailed in? Yes No How Did You Respond to This Offer? How did you respond to this offer? Response Mailed to a Different Address: Yes No Do you have a Tracking Number? (Certified, Insured or Express Mail)? Yes No What did you receive? max size 250 characters 250 characters max How did it differ from what you expected? max size 250 characters 250 characters max How much did the company ask you to pay ($)? Do you have the item?       How was it delivered? Did you contact the company or person about the complaint? Yes No Did You Lose Money? Lose Money: Yes No Type of Mail Fraud Complaint Scheme Category: Scheme Type: Additional Information max size 1000 characters 1000 characters max Privacy Act Statement: Your information will be used to support investigations of criminal, civil, or administrative matters. Collection is authorized by 39 U.S.C. 401 and 404; and 18 U.S.C. 3061.

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provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal operations. 

OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including

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In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities.

• The Joint Commission Office of Quality Monitoring at (800) 994-6610 or complaint@jointcommission.org.•

Franciscan Health and Wellness Services, Inc,  

Franciscan Missionaries of Our Lady Health System Holdings, Inc

Franciscan Missionaries of Our Lady Health System Management Services-New Orleans East, LLC 

Franciscan Missionaries of Our Lady Health System, Inc

Franciscan Missionaries of Our Lady Health Systems Management Services, LLC

 

Franciscan Missionaries of Our Lady of Health System Clinical Network, LLC

 

LSU-OLOL Psychiartry Residency Program

 

 LSU-Our Lady of the Lake Psychology Residency Program

 

Louisiana State University Health Sciences Center

 

Louisiana State University System

 

Our Lady of the Lake Hospital, Inc.

 

Our Lady of the Lake Physicians Group, LLC

 

OLOL-RMC

 

OLOL-RMC (Trademark)

 

Franciscan Missionaries of Our Lady Health System, Inc ("FMOLHS")

 

FMOLHS sponsored organizations include, but are not limited to:  

OLOL-RMC, Inc.;

Our Lady of the Lake Children's Hospital; 

Our Lady of Lourdes Regional Medical Center, Inc.; 

St. Francis Medical Center, Inc., 

Our Lady of the Lake Ascension; 

Our Lady of the Angels Hospital; 

Franciscan Missionaries of Our Lady University (FranU)

St. Dominic Health Services

Centers for Medicare & Medicaid Services  Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal An enrollee or an enrollee's representative may use the form “Request for an Administrative Law Judge (ALJ)

“Request an Administrative Law Judge (ALJ) OMHA-100” to request  a review of an Independent Review Entity's dismissal

 “OMHA-100” Office of Medicare Hearings and Appeals

Section 1: Which Medicare Part are you appealing (if known)? (Check one) 

Part A Part B Part C (Medicare Advantage) or Medicare Cost Plan Part D (Prescription Drug Plan)

Section 2: Which party are you? (Check one) The Medicare beneficiary you received or requested the items or services being appealed


Section 3: What is your (the appealing party's) information?

Name (First, Middle Initial, Last) Firm or Organization (if applicable) Address where appeals correspondence should be sent City State ZIP Code Telephone Number Fax Number E-Mail

Section 5: What is being appealed?

Submit a separate request for each Dismissal that you wish to appeal. If the appeal involves multiple beneficiaries, use the multiple claim attachment (OMHA-100A).

Name of entity that issued Dismissal (or attach a copy of Dismissal or attach a copy of Dismissal) YOUR  Name Health Insurance Claim Number YOUR Mailing Address City State ZIP Code

What item(s) or service(s) are you appealing? (N/A if appealing a Dismissal)
Date(s) of service being appealed (if applicable)

Section 6: For appeals of prescription drugs

What drug(s) are you appealing?

Are you requesting an expedited hearing? (An expedited hearing is only available if your appeal is not solely related to payment (for example, you do not have the drug), and applying the standard time frame for a decision (90 days) may jeopardize your health, life, or ability to regain maximum function)

On a separate sheet, please explain or have your prescriber explain why applying the standard time frame for a decision (90 days) may jeopardize your health, life, or ability to regain maximum function.

Section 7: Why do you disagree with Dismissal being appealed? (Attach a continuation sheet if necessary)

Section 8: Are you submitting evidence with this request, or do you plan to submit evidence? I am not planning to submit evidence at this time.

Section 9

I am submitting evidence with this request. I plan to submit evidence. Indicate what you plan to submit and when you plan to submit it: Was the evidence already submitted for the matter that you are appealing?

Section 9: Is there other information about your appeal that we should know?

Are you waiving the oral hearing before an ALJ and requesting a decision based on the record? (If yes, attach a completed form OMHA-104 or other explanation.

N/A if requesting review of dismissal.

Section 10: Certification of copies sent to other parties (Part A and Part B appeals only)

If another party to the claim or issue that you are appealing was sent a copy of Dismissal, you must send a copy of your request for an ALJ hearing or review of dismissal to that party.

Check here if no other parties were sent a copy of Dismissal.

Section 11: Filing instructions

send your request to:

OMHA Central Operations Attn: Beneficiary Mail Stop 1001 Lakeside Ave., Suite 930 Cleveland, Ohio 44114-1158

For expedited Part D appeals, send your request to: OMHA Central Operations Attn: Expedited Part D Mail Stop 1001 Lakeside Ave., Suite 930 Cleveland, Ohio 44114-1158

We must receive this request within 60 calendar days after you received Dismissal that you are appealing.

We will assume that you received Dismissal 5 calendar days after the date of Dismissal, unless you provide evidence to the contrary.

If you are filing this request late, attach a completed form OMHA-103 or other explanation for the late filing.
Section III on the front of this form can be used for that purpose.

Where to Send This 

 to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB Exempt MEDICARE REDETERMINATION REQUEST FORM — 1st LEVEL OF APPEAL

Beneficiary’s name (First, Middle, Last)
Medicare number
Date the service or item was received (mm/dd/yyyy)
Item or service you wish to appeal
Date of the initial determination notice (mm/dd/yyyy)
(please include a copy of the notice with this request)

If you received your initial determination notice more than 120 days ago, include your reason for the late filing:

Name of the Medicare contractor that made the determination (not required)

Denial Notice Medicare health plans are required to issue the Notice of Denial of Medical Coverage, also known as the Integrated Denial Notice (IDN), upon denial, in whole or in part, of an enrollee's request for coverage and upon discontinuation or reduction of a previously authorized course of treatment.

To download the IDN and its corresponding instructions, please click on the links below under "Downloads."

Questions regarding the IDN can be submitted to: Form CMS 10003-NDMCP OMB Approval 0938-0829 (Expires: 02/28/2023)

Form Instructions for the Notice of Denial of Medical Coverage CMS-10003-NDMCP

A Medicare health plan (“plan”) must complete and issue this notice to enrollees when it denies, in whole or in part, a request for a medical service/item, Part B drug or Medicaid drug, or a request for payment of a medical service/item or Part B drug, or Medicaid drug the enrollee has already received.

Evidence of Coverage (Enrollee Handbook), as solely a Medicaid benefit 

• The medical service/item or Part B drug or Medicaid drug was previously approved solely under the plan’s Medicaid benefits, and the request is for reauthorization or payment for services following such approval (see below for more discussion);

• (Medicaid-only services are generally limited to non-medical services such as Medicaid home- and community-based long term services and supports that the plan is contracted to provide to eligible Medicaid beneficiaries, such as personal care attendants.

Integrated plans should work with their states to develop a definitive list of these Medicaid-only services.).

If the request is classified by the plan as a request for payment or coverage under the 1 Effective January 2021, other plans that provide both Medicare and Medicaid benefits that are “applicable integrated plans” under 42 C.F.R. § 422.561 should follow the notice requirements for integrated organization determinations and reconsiderations under 42 C.F.R. §§ 422.629 through 422.634.

 

In the title to this section, insert the health plan name.

Form CMS 10003-NDMCP OMB Approval 0938-0829 (Expires: 02/28/2023)

Medicare-Medicaid Plans (MMPs) within the Financial Alignment Demonstrations also will use the IDN.

    If the action taken involves Medicaid benefits, insert text shown in the square brackets, as applicable.

    In the title to this section, insert the health plan name.

If the request is classified as a request for only Medicaid coverage, and the plan denies coverage or payment in whole or in part under the plan’s Medicaid benefits, then the plan should send any notices required to meet state Medicaid notice requirements.

When an integrated D-SNP receives a request for payment or coverage that cannot be readily classified falling solely under the plan’s Medicaid benefits (e.g., the request is for a service with overlapping Medicare and Medicaid coverage a home health aide), and the plan determines the service/item  is not covered under the plan benefits, but is fully covered under the plan’s Medicaid benefits, then the plan must send a notice informing the plan enrollee of the denial of Medicare coverage and the relevant Medicare appeal rights.

Section: You have the right to appeal our decision

The plan must insert its name in the {health plan name} field.
If the action taken involves Medicaid benefits, insert text shown in the square brackets, as applicable.

If the enrollee is not required to exhaust the plan level appeal before requesting a State Fair Hearing, the notice must inform the enrollee of the right to concurrently request a plan appeal and a State Fair Hearing.

The plan must insert applicable time frames for requesting a State Fair Hearing.

Section: The plan must insert the phone and TTY numbers to be used if  enrollee needs information on how to name a representative.

Section: There are 2 kinds of appeals with {health plan name}

Standard Appeal - As applicable, the plan must insert the appropriate adjudication timeframe for Medicare medical services/items or Part B drugs, or standard Medicaid appeals.

Form CMS 10003-NDMCP OMB Approval 0938-0829 (Expires: 02/28/2023)

Fast Appeal - As applicable, the plan must insert the appropriate adjudication timeframe for medical services/items or Part B drugs or Medicaid drugs.

     Section: How to ask for an appeal with {health plan name}
 
     Step 1:
If the plan requires the appeal to be in writing, insert the bracketed option of written.
If the notice relates to a Medicaid service, insert the italicized text shown in the square brackets.

     Step 2:
In the spaces provided for Standard and Fast Appeals, the plan must insert the plan's address, phone and fax number(s).
If the plan accepts standard appeal requests by phone and/or electronically, insert the text shown in brackets.

     Section: What happens next?

If the notice involves a Medicaid service, the plan must insert Medicaid/State contact information. If applicable, the plan should insert state/local disability and aging services contact information.