CMS Pub. 100-04, ch. 32, § 360.3.7

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

(MAC’S NAME AND ADDRESS)

Date: ____________________

Beneficiary: _________________________

Claim Number: __________________

DETERMINATION ON SHIPBOARD SERVICES

We are sorry, but medical services provided on the (vessel/ship's name) cruise ship are not covered. The Medicare

program can make payment for medically necessary shipboard services only if all of the following requirements are met:

1. The services are furnished while the ship is within the territorial waters of the United States (in a U.S. port, or

within 6 hours of departure or arrival at a U.S. port).

2. The services are furnished to an individual who is entitled to Part B benefits;

3. The services are furnished in connection with covered inpatient hospital services;

4. The services furnished on the ship are for the same condition that required inpatient admission;

5. The physician is legally authorized to practice in the country where he or she furnishes the services.

If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they

cover these services and what procedures you should follow in submitting your claim.

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,