March 31, 2025
IPAs must use updated letter templates
The Centers for Medicare & Medicaid Services (CMS) has announced changes to appeal submission timelines, aimed at providing additional time for members and non-contracted providers to initiate an appeal. These updates officially took effect on January 1, 2025.
Key changes to appeal timelines
- Extended appeal timeframe: The timeframe to request an appeal has been extended from 60 calendar days to 65 calendar days from the date on the initial notice.
- Dismissal review requests: Similarly, the timeframe for submitting a request to review a dismissal with the independent review entity (IRE) is now 65 calendar days from the date of the plan’s dismissal notice.
- No change to adjudication timelines: The time required for the Plan to review and adjudicate these requests remains unchanged.
What this means for IPAs
Effective January 1, 2025, independent practice associations (IPAs) must use the updated notification and denial letter templates for members and non-contracted providers. The templates are posted on the Health Industry Collaboration Effort (HICE) website. Visit the HICE website at iceforhealth.org to download copies of the templates with updated timelines.
- Notice of Denial of Medical Coverage (or Payment) (NDMCP)
- AIP Coverage Decision Letter
- Notice of Medicare Non-Coverage (NOMNC)
- Detailed Explanation of Non-Coverage (DENC) (update pending)
- Waiver of Liability (WOL)
Additional Information
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at www.wellcare.com/California/Providers/Medicare. If you have questions regarding the information contained in this update, contact 866 999 3945.
