Medicare Redetermination Notice (for Fully Favorable

310.8 - Medicare Redetermination Notice (for Fully Favorable 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