405.921—Notice of initial determination.
(a) Notice of initial determination sent to the beneficiary.
(1)
The notice must be written in a manner calculated to be understood by the beneficiary, and sent to the last known address of the beneficiary;
(i)
The reasons for the determination, including whether a local medical review policy, a local coverage determination, or national coverage determination was applied;
(ii)
The procedures for obtaining additional information concerning the contractor's determination, such as a specific provision of the policy, manual, law or regulation used in making the determination;
(iii)
Information on the right to a redetermination if the beneficiary is dissatisfied with the outcome of the initial determination and instructions on how to request a redetermination; and
(b) Notice of initial determination sent to providers and suppliers.
(1)
An electronic or paper remittance advice (RA) notice is the notice of initial determination sent to providers and suppliers that accept assignment. The electronic RA must comply with the format and content requirements of the standard adopted for national use by covered entities under the Health Insurance Portability and Accountability Act (HIPAA) and related CMS manual instructions. When a paper RA is mailed, it must comply with CMS manual instructions that parallel the HIPAA data content and coding requirements.
(ii)
Information on the right to a redetermination if the provider or supplier is dissatisfied with the outcome of the initial determination;
(iv)
The source of the RA and who may be contacted if the provider or supplier requires further information;
(v)
All content requirements of the standard adopted for national use by covered entities under HIPAA; and