(Medicare Claims Processing Manual)

When the  QIC receives a request for reconsi deration, it will re quest the  case file from the MAC  with ju risdiction using the Redetermination C ase File Request Form.  The  QIC will s end the  request either by email, telephone , fax, or by any other method a greed upon in the J OAs.  ( Note:  Individua lly identifiable beneficiary information should not be  given in a n uns ecure email.)  If another method is a greed upo n in the  JOAs, it mu st meet the  privacy requirements of  HIPAA.  If agreed upon in the  JOAs, the  following re quirements apply to email, fax and phone  requests:  (a) Email requests - MACs sh all ma intain an email account speci fically for the receipt of  case file requests from the  QIC.  If individually identifiable information is given in the re quest or respons e, a secure email account must be  used.  MACs must  check this e mail account a t least onc e daily (every business day).  When MACs r eceive email requests from the  QIC, they shall notif y the QIC of receipt.   (b) Phone  Requests - MACs sh all designate and m aintain a phone  extension speci fically for the receipt of case  file requests fro m the  QIC.  MACs  shall designate a main contact p erson and ba ck-up contact th at is a vailable to take phone  calls du ring core busine ss hour s on a ll busin ess days (unless oth erwise agreed upon in the  JOAs).  (c) Fax Requests - MACs sh all designate and m aintain a fax machine  for the receipt of  case  file requests fr om the QIC.   320.5 - QIC Case File Preparation  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Once a party requests a reconside ration with a  QIC, the QIC will n eed to o btain the  case  file from the  MAC that issu ed the  redeterminatio n decision.  The  founda tion for an effective, efficient and accurate appeals s ystem is the  case  file.  It is e ssential that the case  file contain all relevant information a nd evidence concerning an appeal in an organiz ed manner so th at the QIC can m ake a correct and fair determination.  The  MAC  prepares the case file by s eparating procedural doc uments   and medical do cuments and builds the  case  file from the  bottom up, with the  olde st set of documents on the  bottom, a nd the  most recent s et of documents at the top.  How ever, it doe s not pl ace the medical doc umentation on the  bottom.  M edical do cumentation doe s not nee d to be  ordered chronologically, but r ather can be included in t he case  file as submitte d by the provide r.  For large  cases containing multiple  beneficiary files, the  MAC shall organize  the case fil es by individual be neficiary files in alphabe tical order.  A packing list w ill be included for m ultiple beneficiary box c ases and lab eled as box n umber x of  y.  As the MACs begin utilizing the MAS for processing redeterminations (timeframe by jurisdiction TBD), the MACs shall work to update their JOAs with QICs to include language indicating that the appeals case file will be obtained via electronic promotion of t he level one appeal record within the MAS.  The MAC QIC JOAs shall include language to address situations in which the MAS is down or otherwise unavailable for short term and/or long term periods of time.  In addition, the JOA shall include language to address processes and procedures for providing case files that are not in the MAS due to the redetermination having been processed prior to the level one MAS implementation and/or the rare instance that the file is otherwise not available in the MAS.   For one  QIC case add ressing multiple  beneficiaries, parti cularly  large multi- beneficiary and overpayment cases, the  MAC shall keep the  documents relating to e ach beneficiary toge ther and organiz ed alphabe tically by be neficiary last nam e.  Documents relating to e ach beneficiary will be  separat ed and a c omplete set of pro cedural doc uments w ill be  provided for e ach beneficiary.  The following is a list of  the documents ge nerally included in a ny case file.  Note  that there may be other s not liste d here .  For applicable items, the  MAC i ncludes originals and re tains ha rd copies of any documents th at are not a vailable electronically for its reco rds.  Do not s end abbreviated versions, or versions of  documents that the MAC  has retyped or paraphrased for pur poses of shor tening the document.  The  MAC must k eep a n exact copy of the file that is sent to the  QIC.  (Note:  This applies onl y when documents ar e not othe rwise available e lectronically.)  If it is un able to include the original doc uments, it in cludes photoc opies that are true facsimile s of the original doc uments.  It arranges the following documents, in de scendi ng date order (i.e., the  claim form is on the  bottom ). Procedur al Do cuments:   Claim form or printout, if  electronically generated (fac simile  and/or  screen prints are acceptable);   MSN/RA - olde r files may contain EOM Bs or Denial Letters, whi ch must a lso be included.  (Facsimile  and/or screen prints a re acceptable);   Redetermination re quest;   Redetermination noti ce;   Appointm ent of representative form (F orm CMS-1696)  or othe r written author ization, if  applicable;     All do cumentation re lated to the  assessment of an over payment.  Med ical Do cuments:   Medical records, separated by facilit y, doc tor, or location of  service (separated by a colore d she et or a sheet of paper with a  headi ng);   Referral to/from MAC  medical st aff (with p rofession al qua lifications o f the reviewer noted in the  document, if  applicable)   MAC  medical poli cies and opinions re levant to claim(s).  (In addition to MAC medical poli cy, the MAC  should inc lude in the case  file any information it h as as back ground to the  particular policy at issu e.  For example, finding s of the MAC  advisor y committe e (CAC) with re gard to the  policy, including profession al publi cations re lied upon to suppor t the policy, opin ions from pr ofession al medical societies who m ay have comm ented on the  policy during the developm ent ph ase, etc.)  (See the Program Integrity Manual, Pub. 100- 08 for addition al information.) ;*   A list of  relevant por tions of  the law, regulations, C MS rulings, national coverage determinations/d ecisions, a nd C MS manuals;   Copies of LCDs, n ewsletters, any other pertinent information th at may be used by the QIC;*   Any other exhibits th at the MAC m ay conside r impo rtant for the QIC to conside r (e.g., certification of  reasonable charge, fee schedule information, noti ces of nonc overage, MAC publi cations.) ; and   Any additiona l evidence submitte d by the appellant.  *If accessible  by internet, the  MAC that issu ed the  redetermination d ecision may  enter into a  joint operating a greement with the  QIC to pr ovide a list instead of  actual copies.  Assembly Instructions:   The MAC us es an appropriate file/folder/envelope which will c ontain necessary documents in pr oper order, if the case file is not t ransmitte d electronically.   For combine d requests filed by a beneficiary, the MAC  keeps the  documents relating to t reatment from e ach pr ovider , physician, or supplier together.  It separates the documents relating to each p rovider, physician or suppli er by a blank sheet of  paper;   For combine d requests filed by a provider , physician, or othe r suppli er, the MAC keeps the  documents relating to each beneficiary together and or ganized   alphabetically by beneficiary last name.  It separat es the documents relating to each b eneficiary by a blank she et of p aper.  It provides a complete set of procedural doc uments for each be neficiary; and   The MAC  groups pr ocedura l documents toge ther in chronological o rder and groups m edical doc uments together in chronological order.  Recon sideration Case  Transmittal Form  The Reconside ration C ase Transmitta l Form documents the  claim in formation a nd the  date of the redetermination.  It also ide ntifies the MAC t hat made the redetermination a nd the  QIC with jurisdiction f or the reconsid eration.  The  summ ary sheet should be  placed on top of  the doc uments in the case  file.  The  QIC will p rovide  a Reconside ration C ase Transmitta l Form for use  in the  JOA.  320.6 - Forwarding QIC Case Files (Rev.  4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  MACs sh all send/transmit the  case  file within 7 ca lendar days of the date of the QIC's request.  The  date of QIC's request is d efined as the date the phone call is ma de (if a message is left, it is d efined as the date the message was left) or the date of the email request.  The  case files must be  sent either by an electronic means agreed upon in the  joint opera ting agreem ent or by a courier service so tha t the case file is received by the QIC before or on the  8th cal endar day after its re quest.  T he MAC c ounts the costs asso ciated with sending c ase fil es in the  Contra ctor Administrative  Budge t and Financ ial Manag ement (CAFM) code designat ed for pr eparing/transf erring c ase fil es to the  QIC.  320.7 - QIC Jurisdictions  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  A.  Part A  QIC J urisdictions  The Part A Q IC jurisdictions ar e as follows:     Jurisdiction  Normal States  Exceptions  Part A E ast QIC jurisdiction Alabama, Ar kansas, Colorado, C onnectic ut, Delaware, Florida, Georgia, L ouisiana, M aine, Maryland, M ississippi, Massachusetts, N ew Hampshir e, New Mex ico, New Jersey, New York, Texas, O klahoma, N orth Carolina, P ennsylvania, Puerto Ri co, Rhode I sland, South C arolina, T ennessee, Vermont, Virgin I slands, Virginia, W est Virginia, and W ashington DC  and Mutua l of Omaha claims where the service was rendered in one  of the above  listed States. Chain Providers (including ESRD)  the St ate where the MAC  processed the  claim.  F or providers who pr eviously submitte d claims to Mutua l of Omaha (currently processe d by WPS), the jurisdiction c ontinue s to be  the St ate where the service was rendered.  Indian  Health Services claims Nationwide  Foreign claims- Eastern Mexico, Canadian Provinces of  New Brunswick, Newfoundl and, Nova  Scotia, Quebec, and Prince Edw ard Island  Rural Health Clinic claims Nationwide Part A West QIC jurisdiction