Integrated Denial Notification - Notice of Denial Medical Coverage Template Information
Provider Type
- Participating Physician Groups (PPG)
All Medicare Advantage Organizations (MAOs), including providers and delegated participating physician groups (PPGs) must issue the Integrated Denial Notice (IDN) - Notice of Denial of Medical Coverage (NDMC) letter to members when the delegated PPG denies in whole or in part, a request for a medical service/item. This may include cases when the delegated PPG denies a medical service requested by the member. A decision must be made as expeditiously as the member's health condition requires. Refer to the Centers for Medicare & Medicaid (CMS) website at www.cms.gov for downloading CMS-approved templates.
Applicable Integrated Plan (AIP) coverage decision letter for DSNP members in Exclusively Aligned Enrollment (EAE) counties
The Applicable Integrated Plan (AIP) Coverage Decision Letter is used instead of the Integrated Denial Notification form for the DSNP members in EAE counties. The AIP Coverage Decision Letter is available in Delegation Oversight Interactive Tool (DOIT) for PPGs to access.
Refer to the below table to see the scenarios where PPGs are responsible for sending out the AIP Coverage Decision Letter. This will help PPGs determine when to forward the authorizations to the Plan and when to send the Applicable Integrated Plan Coverage Decision Letter for DSNP members in EAE counties.
Scenario | Delegated PPG | Health Plan |
|---|---|---|
Eligibility denial | Deny and send AIP coverage decision letter. | N/A |
Medical necessity denial | Deny and send AIP coverage decision letter. | N/A |
Scenarios where PPGs would be responsible for forwarding the request to the Health Plan
Scenario | Delegated PPG | Health Plan |
|---|---|---|
Benefit denial | Forward to Health Plan with the Medicare clinical decision. | Deny and send AIP coverage decision letter. |
Out of network | Forward to Health Plan with the Medicare clinical decision. | Deny and send AIP coverage decision letter. |