(Medicare Program Integrity Manual)

The election to be a participant or a party to a hearing after receipt of the formal NOH shall be made consistent with 42 CFR 405.1010(b) or 42 CFR 405.1012, respectively, and the CMS-prescribed prioritization process, described below. If through the CMS- prescribed prioritization process it is determined that the contractor may act as either the party or a participant to a hearing, elections of participation must be sent by the Contractor within 10 calendar days of receipt of the NOH at the AdQIC to all parties listed on the NOH. Submission of a position paper, written testimony, and/or evidence must be submitted no later than five calendar days before the date of the scheduled hearing. Copies of these items must also be sent to those parties listed on the NOH in accordance with 42 CFR 405.1010(c)(3)(ii) and 42 CFR 405.1012(c)(2)(ii).  C. CMS -prescribed Prioritization Process and AdQIC Portal for Providing a Response to the Formal NOH   As the AdQIC is tasked with coordinating contractor interest in participation among the related CMS contractors and/or CMS, all NOHs will be sent directly to  the AdQIC from the OMHA. The AdQIC, within two (2) calendar days of receipt of the formal NOH from OMHA, will create a record in the AdQIC portal that will generate an email notification to all applicable CMS contractors (e.g., DME MAC, A/B MAC, UPIC, SMRC, and/or RAC) notifying them that a hearing has been scheduled.  Upon receipt of the formal NOH e- mail alert, all applicable CMS contractors shall log onto the AdQIC website, https://participation.q2a.com, to access the NOH information. All applicable CMS  contractors shall make their elections, via the AdQIC website, within five (5) calendar days of the formal NOH e-mail sent date. To make an election, contractors must sign-in on the website (see above), and a dashboard will be available listing all appeals for the respective contractor that they may choose to participate in.  Users can also search for appeals based on the information provided in the notification email. Next, the contractors shall select the applicable NOH identifier and complete/submit the  CMS Contractor Participation Form indicating for each appeal whether they would like to participate as a party, participant, or witness, and/or if they would like to call a witness if made a party to the hearing. CMS contractors that fail to sign- in to th e AdQIC system and make their respective participation role selections, in the required timeframe, may be precluded from the prioritization process.  Note: Users will not be able to view the actual NOH document on the site. The web- site/dashboard will allow contractors to view all scheduled hearings for which they received an NOH.   For all NOH communications (e.g., NOHs received from OMHA, NOH email alerts) received after standard business hours (e.g., 4:00 p.m., ET) and/or during weekends or business Holidays, as defined by the respective entity, the AdQIC portal is programmed to calculate the response time beginning with the next applicable business day [e.g., if the AdQIC receives the formal NOH on a Friday at 4:00 pm, the five (5) calendar day timeframe  begins on Monday (with Monday being day zero (0))].  The AdQIC portal will evaluate all submissions received and determine which entity shall have the primary opportunity to participate as a party, and which entities can participate as participants or  witnesses based on CMS prioritization logic.   The anticipated prioritization for the role of party  status is as follows:   1) Primary opportunity for the party role in an ALJ hearing will be granted to the entity that conducted the initial claim denial ( e.g., UPIC, RAC, SMRC or medical review unit within the  MAC).  2) If the entity that issued the initial claim denial does not have interest in participating as a party (due to workload considerations or otherwise) the  QIC will have the primary opportunity to participate as a party.  3) If no CMS contractors and/or CMS wish to invoke party status in a hearing  and multiple entities wish to be a participant, the primary participant shall be the entity that conducted the initial claim denial (e.g., UP IC, RAC, SMRC, or medical review unit within the  MAC).  4) If the entity that identified/conducted the initial claim denial does not wish to be the primary participant on the case, the QIC will have the next opportunity to assume this  role.  The AdQIC portal  will review and prioritize contractor roles in a respective ALJ hearing (i.e., which contractor shall be the party, participants, etc.), within 2 calendar days of receipt of the completed Contractor Participation forms. The website will automatically calculate the contractors Participation Form response due date and each contractors role determination, and prioritize participation elections on the next calendar day after the contractor response timeframe expires. Participation/role designations will be sent via a system -generated email notification to any contractors who expressed interest in participation. The status of elections for a given NOH will be available on the AdQICs website once determinations have been made and notifications have been se nt to the applicable CMS contractors.   On rare occasion, the QIC may need to facilitate a call with the CMS and the related contractors to determine the roles and/or responsibilities on a particular hearing.   Within 10 calendar days from the initial NOH re ceipt date, the AdQIC will reply on behalf of all applicable CMS contractors to the NOH and OMHA with a consolidated response. The consolidated response shall include a Notice of Election form for each applicable CMS contractor for a given NOH.   In the eve nt that OMHA issues an amended NOH, the amended NOH email will be sent from OMHA directly to the AdQIC. The AdQIC will alert all applicable CMS contractors of the amended NOH within 2 calendar days of receipt of the amended NOH email from OMHA. CMS contrac tor participation roles, as determined via the prioritization process in the response to the original NOH and submitted to OMHA via a Notice of Intent (NOI), shall remain intact following issuance of an amended NOH by OMHA. However, if a CMS contractor wis hes to change their method of participation following the receipt of an amended NOH, then the CMS contractor shall notify/work with the AdQIC and OMHA, as applicable (e.g., if another CMS contractor was designated as the Party and the QIC was made a non -party Participant, but now the QIC wishes to serve as a Party following the receipt of an amended NOH, then the QIC must request leave with the ALJ and notify the AdQIC if the request for leave is approved).  D. Communications Outside of the Portal/AdQIC  Process   While the AdQIC and its prioritization portal provide useful vehicles for assessing information transcribed from the notices of hearing received from OMHA and providing formal response, contractors are reminded of regulatory communications that occur outside of this process.  Contractors are reminded that the AdQIC portal and prioritization process is initiated by receipt of an NOH from OMHA. Therefore, Contractors electing status prior to receipt of an NOH shall follow the regulatory process (outlined in 42 CFR 405.1010) to alert OMHA and other parties that were sent a copy of the notice of reconsideration of their intent to participate, which occurs outside of the portal.  In accordance with section of 42 CFR 405.1010(b)(2) and (3), if a contractor elects to participate in an ALJ hearing, the contractor (not the AdQIC) shall provide written notice of its intent to participate to the parties who were sent a copy of an NOH. Failure to notify the other parties to the appeal, of the intent to participa te, may result in the ALJ determining the contractors election for a given NOH invalid. This requirement remains applicable in the event of an amended NOH, and contractors shall ensure compliance. All pertinent information (e.g. party names, mailing addre ss) will be available in the portal for a given NOH.  Additionally, CMS contractors participating or taking party status shall provide copies of all submitted position papers, written testimony, and/or evidence to the ALJ and other appropriate parties within the time frames as set forth in 42 C.F.R. sections 405.1010, 405.1012, or 423.2010, as applicable. Failure to provide copies of submitted position papers, written testimony, and/or evidence within the required timeframe will result in the submissions not being considered by the respective ALJ. Providing copies of all submitted position papers, written testimony, and/or evidence to the appropriate parties remains applicable in the event an amended NOH is issued and contractors shall ensure compliance.   If a contractor requests leave to the ALJ, or formally requests the ALJ to grant the contractor the right to be a secondary party to the hearing, this process occurs outside of the portal.  The ALJ sets the hearing date, time, and method by video teleconferencing (VTC), telephone, or in- person if VTC is not available or special circumstances exist. A party may object in writing to the time and place of the hearing, as soon as possible before the originally scheduled time but no later than 5 calendar days prior to the hearing, and include the reason for the objection along with a proposed alternative date and time. In addition, a party may request an in-person hearing by notifying the ALJ in writing and following the same procedures noted above for an objection to the time/place of the hearing. The ALJ may reschedule if good cause is established per 42 CFR 405.1020(f) or (g).  3.9.2 - Coordination of  the ALJ Hearing  (Rev.  748, Issued: 10- 13-17; Effective: 11 -14-17; Implementation: 11- 14-17)  As needed, if multiple entities are participating in a hearing as a party, participant, or witness, the QIC will set up a brief pre -hearing conference call to discuss the respective entitys participation in the case, roles and responsibilities,  etc.  Examples in which this may be necessary include high dollar cases, extrapolated overpayments, policy implications, and/or fraud related cases, etc.   Pre-hearing briefing topics may include: coordination with OMHA on scheduling matters, the manner o f participation, coordination on position papers or other written testimony submitted, and lessons learned from participation in the ALJ process.    There may be cases in which testimony from another contractor is necessary.  The contractor may call those entities as a witness only if the contractor has declared party status.  However, if the contractor submits a position paper as a participant, the contractor may collaborate with other contractors and document their views on the case in the paper although only one contractor may typically participate via the hearing.    The contractor shall establish a single point of contact for ALJ offices on administrative matters involving notifications, scheduling, information sharing, and other coordination necessary between the ALJ, the appellant, and other contractors.   3.10  Prior Authorization  (Rev. 876; Issued: 04- 12-19; Effective: 05 -13-19; Implementation: 05 -13-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A.  Overview   Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the item or service is furnished to the beneficiary and before the claim is submitted for processing.  It is a process that permits the submitter (e.g., provider, supplier, beneficiary, etc.) to send in medical documentation in advance of providing and billing for an item or service, to verify its eligibility for Medicare claim payment.  Contractors shall, at the direction of CMS or other authorizing entity, conduct prior authorizations and alert the submitter of any potential issues with the information, as submitted.  For any item or service to be covered by Medicare it must:    Be eligible for a defined Medicare benefit category,    Be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functi oning of a malformed body member, and    Meet all other applicable Medicare coverage, coding and payment requirements.  Contractors shall communicate to the submitter (and beneficiary upon request) their prior authorization decision and the assigned unique t racking number (UTN), which indicates that the submitter requested a prior authorization, for corresponding claim submissions.   For certain prior authorization programs, the requirement to prior authorize is a condition of payment, as further described in the sections below.  Absent any explicit CMS instruction to the contrary, submitters may correct identified issues with their prior authorization request(s) and resubmit their request(s) for prior authorization without restriction.  Contractors shall conduct prior authorization reviews within the timeframes defined by CMS in the corresponding prior authorization program operational instruction(s).  The prior authorization process is further described in following sections.  B.  Condition of Payment