US · guidance
CMS Pub. 100-16, ch. mc86c17d, § 40.5
Cost Plan Denial of Enrollment
A cost plan must deny an enrollment based on its own determination of the ineligibility
of the individual to enroll in the plan.
Cost plan denials occur before the organization has transmitted the enrollment to CMS.
For example, it may be obvious that the individual is not eligible to elect the plan due to
place of permanent residence, or that the cost plan is closed for enrollment, etc. This up-front denial determination should be made in a timely manner, but no later than 30
calendar days from the date the organization received the enrollment form.
Notice Requirement - The organization must send written notice of the denial to the
individual that includes an explanation of the reason for denial (Exhibit 5). This notice
should be sent no later than 30 calendar days from the date the organization received the
enrollment form.
If the cost plan is following the procedures in §40.2.2 of this chapter to request additional
information from a beneficiary, the denial notice should be sent within 7 business days of
the denial determination made when the request for additional information period
expires.
History
(Rev. 38, 10-31-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
51e0f96f63eb4ad2f7424940760f9614274e058b43eae020410d354e8dbd6bbf
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