CMS Pub. 100-04, ch. 29, § 310.8

Redeterminations)

(Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19)

NOTE: This activity is NOT required until further notice, unless otherwise specified in the MAC’s statement

of work, except in those situations when the parties will not receive notice of effectuation via a MSN or RA

(MSP overpayments, non-MSP overpayments which do not result in a refund or payment, etc.). MACs will also

have to modify the language to ensure that the letter appropriately addresses the MSP overpayment or non-

overpayment situations.

The MAC uses the redetermination format below, (or something similar) and standard language paragraphs

whether the redetermination notice is delivered via hard copy mail or via a CMS-approved portal/application.

The MAC must ensure that the information identified in each section of the model letter below is included and

addressed, as needed, in the MRN.

(Start)

EXHIBIT 5:

MONTH, DATE, YEAR

APPELLANT NAME MEDICARE NUMBER OF

ADDRESS BENEFICIARY:

CITY, STATE ZIP

CONTACT INFORMATION:

If you have questions, write or

call:

MAC Name

Address

City, State Zip

Telephone number

MEDICARE APPEAL DECISION

RE: <Include claim identifier or appeal number>

Dear <Appellant’s Name>:

This letter is to inform you of the decision on your Medicare appeal. This appeal decision is fully favorable to

you. Our decision is that your claim is covered by Medicare. More information on this decision, including the

amount Medicare will pay, will follow in a future Remittance Advice or Medicare Summary Notice.

For information about filing a request for redetermination, please visit www.medicare.gov/appeals or

http://www.cms.gov/OrgMedFFSAppeals/. Medicare beneficiaries may also contact your State health

insurance assistance program (SHIP). You can find the phone number for your SHIP in your “Medicare &

You” handbook, under the “Helpful Contacts” section of www.medicare.gov Web site, or by calling 1-800-

MEDICARE (1-800-633-4227).

Sincerely,

NAME, TITLE

Model Fully Favorable Redetermination

Notice Coverage Decision

MAC NAME

(End) Exhibit 5