CMS Pub. 100-04, ch. 32, § 360.3.6

The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification

number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim

Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after

for certain business areas that will continue to use the HICN as part of their processes.

MODEL DENIAL NOTICE A

(MAC'S NAME AND ADDRESS)

Date: ______________

Beneficiary: ____________________

Claim Number ________________

DETERMINATION ON EMERGENCY HOSPITAL SERVICES

We are sorry, but payment cannot be made for your stay from________ through________ at (hospital).

Under the law, medical services that have been furnished by a federal hospital to retired members of the armed services,

or their eligible dependents, are not covered under the Medicare program.

If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information.

If you believe the determination is not correct, you may request a redetermination. You must file your request within

120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-20027

or on a written request that includes all of the elements listed below.

• Beneficiary name

• Medicare beneficiary identifier

• Specific service and/or item(s) for which a redetermination is being requested

• Specific date(s) of service

• Signature of the beneficiary or the beneficiary’s authorized or appointed representative.

You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.

Sincerely,