DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration 
  
 Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
 
                   SMDL #01-022 
            July 5, 2001     
             
Dear State Medicaid Director: 
 
The purpose of this letter is to alert you to the enclosed Program Memorandum (PM) on 
Appeals of Medicare Part A/Part B Coverage Determinations issued to Medicare 
intermediaries and carriers.   
 
The key provisions in this PM that apply to State Medicaid agencies and any party authorized to 
act on behalf of the State Medicaid agency are: 
 
1.  All State Medicaid agencies may submit an appeal on behalf of a dual eligible beneficiary 
without beneficiary authorization.  Previously, only a limited number of States were allowed 
to submit appeals on behalf of a dual eligible beneficiary without beneficiary authorization. 
 
2.  Appeals must be filed timely and completed in accordance with Medicare instructions. 
Implied requests for appeal will not be accepted or developed by Medicare contractors.  An 
appeal will not be accepted for any case in which an initial Medicare determination has not 
been made. 
 
Questions on Medicaid policy in this area can be directed to Robert Nakielny at (410) 786-4466 
or by E-mail at rnakielny@hcfa.gov.   
 
Sincerely, 
 
 
  /s/           
 
Penny R. Thompson 
Acting Director 
 
Enclosure 
 
cc: 
CMS Regional Administrators 
 
CMS Associate Regional Administrators  
    for Medicaid and State Operations      
 
  Page 2 - State Medicaid Director 
 
Lee Partridge 
Director, Health Policy Unit 
American Public Human Services Association 
  
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors' Association 
 
Brent Ewig 
Senior Director, Access Policy 
Association of State and Territorial Officials 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
Program Memorandum  Department of Health and 
Human Services (DHHS) 
Intermediaries/Carriers HEALTH CARE FINANCING 
  ADMINISTRATION (HCFA) 
     
Transmittal   AB-00-122    Date:  DECEMBER 7, 2000 
 
    CHANGE REQUEST 1348  
 
SUBJECT:  Appeals of Medicare Part A/Part B Coverage Determinations  
 
This Program Memorandum (PM) clarifies HCFAs policy on appeals submitted by providers, 
suppliers, or Medicaid State agencies or the party authorized to act on behalf of the Medicaid 
State agency for Medicare Part A or Part B claim determinations, including coverage 
determinations, not without fault determinations, and limitation of liability determinations.  This 
PM also revises the HCFA policy by removing the requirement that the Medicaid State agency, 
or its agent, secure written beneficiary authorization prior to its submitting an appeal request to 
HCFA or its Medicare contractors. 
 
This PM refers to appeal requests at the first level of appeal (i.e., requests for reconsideration 
(Part A) and requests for review (Part B)).   
 
Right to an Appeal From a Medicare Part A or Part B Coverage Determination 
 
A beneficiarys right to an appeal for a Medicare Part A or Part B coverage determination is 
afforded by statute (see 1869, 1842(b)(3)(c) of the Social Security Act (the Act)).  The Act 
provides for a hearing where a beneficiary is dissatisfied with the determination of the amount of 
benefits payable under Part A or Part B (including a determination where such amount is 
determined to be zero).  The statute also provides for appeal rights for providers and suppliers in 
certain circumstances (see 1879(d) of the Act).  By regulation, HCFA has further established 
administrative appeals remedies for resolving such disputes that must be exhausted prior to 
securing a right to a hearing. The regulations governing administrative appeals for Part A 
coverage determinations are found at 42 CFR Part 405, Subpart G (Reconsiderations and 
Appeals Under Medicare Part A) and for Part B coverage determinations at 42 CFR Part 405, 
Subpart H (Appeals Under the Medicare Part B program).   These regulations also provide for 
appeal rights with respect to determinations that a beneficiary, provider, or supplier was not 
without fault regarding an overpayment under 1870 of the Act; or knew or reasonably could be 
expected to know that the item or service was not covered, under 1879 of the Act. 
 
Part A: 
 
Regulations at 42 CFR 405.711 require that a request for reconsideration be made in writing and 
filed at an office of HCFA, the Social Security Administration or, in the case of a qualified 
railroad retirement beneficiary, at an office of the Railroad Retirement Board.  The request must 
be filed within 60 days after the date of receipt of notice of initial determination.  Intermediaries 
can not accept an appeal for which no initial determination has been made. A request for 
reconsideration that is filed with the intermediary that received the request for payment 
submitted on behalf of the individual is considered to have been filed with HCFA as of the date 
it is filed with the intermediary.   
 
(See Medicare Intermediary Manual, Part 3 (MIM) 3781.5 - Time Limits for Filing Appeals.)  
HCFA has delegated the authority to extend the time for filing a request for reconsideration to its 
 intermediaries through manual instruction.  (See MIM 3781.6 - Finding Good Cause for the   
 
  Late Filing of Reconsideration Requests.)  
 
HCFA-Pub. 60AB 
 
A request for reconsideration may be filed on Form HCFA-2649, Request for Reconsideration of 
Part A Health Insurance Benefits; however, a signed written statement expressing disagreement 
with the initial determination or indicating that a review or a reexamination should be made, and 
containing the necessary information (as outlined under Contents of an Appeal Request) 
constitutes a request for reconsideration (see MIM 3782.1).  This form is located on the 
hcfa.gov web site at http://www.hcfa.gov/forms/hcfa-2649.pdf. 
 
Contractors should not accept implied request for reviews from providers, suppliers or States or 
the party authorized to act on behalf of the Medicaid State Agency.  MIM 3782.1 is superseded 
in this respect and will be updated to reflect this change.  Returned remittance advices, listings or 
computer printouts that are not signed and/or do not express disagreement with a specified initial 
determination should be returned to the sender.  
 
Part B: 
 
Regulations at 42 CFR 405.807 provide that a party to an initial determination that is dissatisfied 
with such initial determination may request that the carrier (and in some cases, the intermediary) 
review such determination.  The request for review must be filed within 6 months after the date 
of the notice of the initial determination. Carriers can not accept an appeal for which no initial 
determination has been made.  HCFA has delegated the authority to extend the time limit for 
filing an appeal to its carriers through manual instructions (see MCM 12007 - Extension of 
Time Limit for Filing an Appeal) and to its intermediaries through manual instructions (see MIM 
3792 - Extension of Time Limit for Filing an Appeal). 
 
See Medicare Carriers Manual, Part 3 (MCM) 12010 and 12015, subsection D.   
See MIM 3793 and 3794.3, subsection D.  
 
A request for review may be filed on Form HCFA-1964, Request for Review of Part B Medicare 
Claim; however, a signed written statement expressing disagreement with the initial 
determination or indicating that a review or a reexamination should be made, and containing the 
necessary information (as outlined under Contents of an Appeal Request) constitutes a request 
for review (see MCM 12010.1) A copy of Form HCFA-1964 is located on the hcfa.gov web 
site at http://www.hcfa.gov/forms/hcfa-1964.pdf.  
 
Contractors should not accept implied request for reviews from providers, suppliers or States or 
the party authorized to act on behalf of the Medicaid State Agency.  MCM 12010.1.C is 
superseded in this respect and will be updated to reflect this change.  Returned remittance 
advices, listings or computer printouts that are not signed and/or do not express disagreement 
with a specified initial determination should be returned to the sender.  
 
Development of Requests for State-Initiated Appeals 
 
Medicare intermediaries and carriers (hereinafter contractors) should not request documentation 
from a provider or supplier for a State-initiated appeal.  If additional documentation is needed, 
contractors should request that the submitter of the appeal (i.e., the State or the party authorized 
to act on behalf of the Medicaid State agency) obtain and submit necessary documentation.  For 
appeals currently in development, contractors may follow-up with the State or the party 
authorized to act on behalf of the Medicaid State agency, as needed, and complete the appeals 
based on the information available.  
 
Also, States or the party authorized to act on behalf of the Medicaid State agency may request a 
review by telephone, if the appeal request is not complex. If an appeal from the State or the party 
authorized to act on behalf of the Medicaid State agency is complex or if significant 
documentation is needed to adjudicate the appeal request, then a written request for review must   
 
  be filed within the timely filing period. 
 
 
Development of Requests for Provider/Supplier-Initiated Appeals 
 
If additional documentation is needed to process an appeal, contractors should request that the 
submitter of the appeal (i.e., the provider/supplier) obtain and submit it within the prescribed 
time period following notification of an initial determination.  
 
Providers or suppliers may request a review by telephone, if the appeal request is not complex. If 
an appeal from a provider or supplier is complex or if significant documentation is needed to 
adjudicate the appeal request, then a written review must be filed within the timely filing period. 
 
Contents of a Written Request for Reconsideration or Review 
 
For Part A appeals, the Medicare regulation at 42 CFR 405.710 states that a party that is 
dissatisfied with the initial determination may request a reconsideration of such determination.  It 
is clear that the request for reconsideration must be tied to a specific, identifiable initial 
determination.  However, it is not sufficient to simply identify a beneficiary, or a certain time 
period, for example.  The appeal must not only identify the initial determination with which the 
party is dissatisfied, but must also meet the requirements for the contents of an appeal request 
outlined below. 
 
For Part B appeals, the Medicare regulation at 42 CFR 405.807 states that a party who is 
dissatisfied with an initial determination may request that the carrier review such determination.  
Again, the request for review must not only identify the initial determination with which the 
party is dissatisfied, but must also meet the requirements for the contents of an appeal request 
outlined below. 
 
If a fully-completed Form HCFA-2649, Request for Reconsideration of Part A Health 
Insurance Benefits, or Form HCFA-1964, Request for Review of Part B Medicare Claim, is not 
used to express disagreement with the initial determination, then the appeal request must 
contain the following information: 
 
   Beneficiary name; 
 
  Medicare health insurance claim (HIC) number; 
 
  Name and address of provider/supplier of item/service; 
 
  Date of initial determination; 
 
  Date(s) of service for which the initial determination was issued (dates must be reported 
in a  manner that comports with the Medicare claims filing instructions; ranges of dates 
are acceptable only if a range of dates is properly reportable on the Medicare claim 
form); and 
 
  Which item(s), if any, and/or service(s) are at issue in the appeal. 
 
Providers/suppliers, Medicaid State agencies or the party authorized to act on behalf of the 
Medicaid State agency are responsible for submitting documentation, if any, that supports the 
contention that the initial determination was incorrect under Medicare coverage and payment 
policies.  This documentation may be supplied with the appeal request or at the request of the 
contractor.  Failure to submit requested documentation in a timely manner may result in 
processing delays. 
 
Who Can Submit Appeal Requests 
   
 
  With the issuance of this PM, Medicaid State agencies and parties authorized to act on behalf of 
Medicaid State agencies may submit an appeal request on behalf of beneficiaries entitled to 
Medicare and eligible for Medicaid.    
 
NOTE:  On and after the effective date of this PM, the Medicaid State agency 
or the party authorized to act on behalf of the Medicaid State agency 
should  cease  submitting  beneficiary  authorization  forms  or  other 
beneficiary representation forms with the appeal request.  
 
Additionally, the following parties may continue to submit an appeal request: 
 
  Providers, as defined in 42 CFR 400.202, with appeal rights as specified in regulation at 
42 CFR405.710(b). 
 
  Suppliers (including physicians, as defined in 42 CFR 400.202) with appeal rights as 
specified in regulations at 405.801(b), accepting assignment on the claim at issue, and 
suppliers with refund requirements under 1842(l)(1), 1834(a)(18), or 1834(j)(4) of the 
Act. 
 
  Beneficiaries and their authorized representatives. 
 
Medicare Contractor Responsibilities Include (but are not limited to): 
 
See MIM 3780 et. seq. 
See MCM 12000 et. seq. 
 
  Medicare contractors must issue to all providers and suppliers, through contractor 
bulletins and other available means (e.g., available on website), the following sections 
of this PM: 
 
  -   Development of Request for Provider/Supplier-Initiated Appeals 
    -  Contents of a Written Request for Reconsideration or Review 
 
  Reviews all requests for appeal to ensure that requests meet the requirements listed in 
this PM and contained in manual instructions. 
 
  Notifies an appellant when a request for appeal has not met the filing requirements. 
 
  Requests documentation, when needed, from the appellant. 
 
  Notifies an appellant of the results of its appeal request. 
 
The effective date for this PM is December 1, 2000.  In addition, with regard to written 
beneficiary authorization, this PM is retroactive to all currently pending requests for appeal from 
Medicaid State agencies (that is, all pending requests for appeal do not require beneficiary 
authorization from the Medicaid State agency or its agent). 
 
The implementation date for this PM is December 7, 2000. 
 
The effective date for this PM is December 1, 2000. 
 
These instructions should be implemented within your current operating budget. 
 
This PM may be discarded December 31, 2001. 
 
Providers/suppliers are to contact their appropriate intermediary or carrier. 
   
 
  If you have any questions, contact Lisa Childress at (410) 786-6956.