(Medicare Claims Processing Manual)

NOT E:  If a party  files a request for reco nsideration  with the  contra ctor after a redetermination d ecision or dismissal no tice has b een issu ed, the  contra ctor tr eats the  reconside ration r equest as misfile d and f orwards the request to the  QIC for a r econside ration in a ccordan ce with 320.1.B.   Contracto rs shall not issue a dismiss al noti ce in response  to a dupli cate request or multiple r equests for redetermina tion.  NOTE: In accordance with IOM 100- 04, c hapter 29, s ection 310.6.3, if  an appellant requests th at the contractor vacate its dismiss al action, or  an app ellant ref iles a corrected appeal in re spons e to a dismiss al, and the  contractor  determines that it cannot vacat e the dismiss al, then it s ends a l etter notifying the appellant accordingly.  If evidence or information not previously submitted with the redetermination request is submitted with the request to vacate the dismissal, the letter must specifically address that new evidence or information.  T he contractor shall not issue  a second dismiss al noti ce to the  appellant.  5.  L etters a nd Calls Th at Are Considered  Inquiries  See IOM 100-09, M edicare Contractor  Beneficiary and Provide r Communi cations M anual. The c ontractor consider s the letter or telephon e call a n inqui ry (i.e., not  an appeal request) if:   It is c learly limite d to a  request for an explanation of  how M edicare calculated pa yment.  (For example, if a ph ysician sends a l etter inquiring about the  payment rate for a parti cular ite m or service, but it is not in c onnection w ith a c laim that has  been proces sed for the  item or s ervice, the letter is tr eated as an inqui ry.  Ho wever, if the  phys ician que stions the amount paid for an item or s ervice on a  claim that w as pro cesse d to pa yment, and ass erts additional pa yment is warrant ed, the  contra ctor handl es this as an app eal of the  payment amount, even if the  item/service was paid unde r a fee schedule.  See 200. C.3);   The party  is only as king for the  status on a  previous ly submitte d appeal r equest or correspond ence.  The contractor  states in its reply that is re sponding to a status re quest.  It does not use  the word review in its re ply;   It is a  request for information;   It is a r equest for re determination, made  by a party  othe r than the  appellant, for the  same item/service for which a d ecision or dismissal noti ce has alr eady been issu ed.  In responding to the inquir y, the  contra ctor shall inf orm the  party  making the  request that a d ecision has b een issued and the  party  should file  a reconside ration w ith th e appropriate Q IC.  Contra ctors shall  not issue  a dismissal noti ce.   It is a r equest for re determination, submitte d by an indi vidual ( who is not an appoint ed or authoriz ed representative ), filed on behalf of a pro vider, physi cian, suppli er, or othe r non-beneficiary party, and the  request doe s not inc lude an appointm ent instrum ent (see 270.1.6.B.2) .  The contractor follo ws the procedur es in 270.1.6.B.2.   The party asks onl y for a second c opy of a notice.  NOTE:   If the contractor  receives a request for reconside ration  (assuming the appellant is using the wrong form or incorrect terminolo gy), but de termines that a redetermination ha s not b een c onduc ted, the  contractor  does not f orward the  request to the  QIC.  The contractor sh all conside r the request as a redetermination r equest.   If the contractor receives a request for reconsideration from a party, or a 'request for reconsideration' that was mistakenly directed to them by another contractor, and the contractor has already conducted a redetermination, the contractor shall forward the request  to the  appropriate QIC, along with the  case  file within 60 cal endar days of receipt in the  corporate mailroom. Refer to 320.1.  Parties to a  claim must f ile a request for redetermination with the  proper contractor  based on the c laims processi ng jurisdiction r ules establish ed by the Medicare program.  Jurisdiction is establish ed based on either the State where the service was provided (for  Part B claims n ot involving DME ), the State where the beneficiary resides (for  Part B DME  claims on ly), or the lo cation of  the A/B MAC (for Part A p rovide r claims).  There may be inst ances wh ere requests for redetermination a re directed to the  wrong contractor.  Contractors shall have standard operational procedur es, inc luding maintaining a record of these cases, in place to ensure that misfiled  requests are forwarded to the  proper contractor jurisdiction within 60 ca lendar days of receipt.  Refer to  310.4.A for information on determining whether misfiled requests for appeal are processed in a timely manner.   310.2 - Time Limit for Filing a Request for Redetermination  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A party must f ile a redetermination re quest within 120 da ys of the date of receipt of  the notice of initi al determination ( MSN or RA) with the  contractor indicated on the  notice of initia l determination (receipt of the notice of initial d etermination is pr esumed to be  5 da ys aft er the date of the  MSN or RA unl ess there is evidence to the contrar y).  The  date of filing for requests filed in w riting is defined as the date received by the appropriate contractor  in the  corporate mailroom, the  date received via  facsimile , or the date received in the secure Internet por tal/application, as evidenced by the receiving offices date stamp on the request.  I f the party has filed the  request in p erson with the  contractor, the filing date is the  date of filing at such office, as evidenced by the receiving offices date stamp on the  request.  If the party has mailed or filed in person the request for redetermination to a C MS, SSA, R RB office, or anothe r contractor  or Gov ernment agency within the  time  limit, a nd the  request did not reach the a ppropriate contractor until after the time  period to file a request expired, the  contractor  shall consider the date the request was first filed with a contractor or an official Federal government entity as the date of receipt for purposes of determining if the redetermination request was filed in a timely manner .   When the  filing d eadline  for a re determination e nds on a Saturda y, Sunda y, legal holida y, or any othe r nonw ork day, the  contra ctor shall apply a r ollover period that ex tends the  filing de adline to the  first w orking day after the Saturda y, Sunda y, legal holida y, or othe r nonw ork day.  For ex ampl e, if the  filing d eadline  for a redetermination falls on the  Saturday  before Columbus Da y, the  filing d eadline  is ex tended to the  first working day after the Columbus Day holida y.  The contractor may extend the  period for filing if it finds the  party had good cause  for not re questing the redetermination time ly.  (See 240. 2 for a discussion of  good caus e.)  In order for good cause to be  conside red, the  appeal request must be  in w riting, received via  hard copy mail, through a facsimile , or through a secure Internet portal/application.  If the contractor  finds tha t the party did not ha ve good cause  for failing to request a redetermination in a  timely manner, it ma y, at its dis cretion, c onside r reopening.  (See Pub. 100- 04, c hapter 34.)  310.3 - Reporting Redetermination on the Appeals Report  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07-23 -13)  The MAC is re quired to re port all appeals related data and inf ormation on the  CMS App eals R eport.  The  Report is inte nded to captu re information on a ppeal re quests, in cluding oth er corresponde nce that is determined to be  a request for re determination.  C orresponde nce that initially  appears to be  an inquir y, but is determin ed to be  an app eal request, must be  reported as a r edetermination r eceipt  and not an inquir y.  310.4 - The Redetermination  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A.  Timely Processing Requirements   The contractor must complete and mail a redetermination notice for all requests for redetermination within 60 days of receipt of the request (with the exception of (D)(4) below). The date of receipt for purposes of this standard is defined as the date the request for redetermination is received in the corporate mailroom or the date when the electronic request for appeal is received via facsimile or through the secure Internet portal/application.  For misfiled redetermination requests, the proper contractor jurisdiction must complete and mail a redetermination notice within 60 days of receiving the misfiled request in their corporate mailroom.   Completion means:   1. For affirmations (unfavorable decisions), the date the decision letter is mailed to all of  the parties (or their representatives). Affirmations processed via a CMS approved secure Internet portal/application shall be considered complete on the date the electronic redetermination notice is transmitted to the appellant through the secure Internet  portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure Internet portal/application.  See 310.10 for additional requirements related to notices sent via secure portal/applications.   2. For partial reversals (partially favorable decisions) and full reversals (fully favorable decisions), when all of the following actions have been completed:   a. The decision letter, if applicable, is mailed to the parties.  If the redetermination is processed via a CMS approved secure Internet portal/application, it shall be considered complete on the date the electronic redetermination notice is transmitted to  the appellant through the secure Internet portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure Internet portal/application.  See 310.10 for additional requirements related to notices sent via secure portal/ applications, a nd  b. The actions to initiate the adjustment action in the claims processing system are taken.  When the adjustment action is completed, this action must be included on the next scheduled release of the MSN/RA.  Appropriate follow -up action should be taken to ensure that the adjustment action results in the issuance of proper payment.  3. For withdrawals and dismissals, the date the dismissal notice is mailed. If the redetermination is processed via a CMS approved secure Internet portal/application, it shall be considered complete on the date the notice is transmitted to the appellant throu gh the secure Internet portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure Internet portal/application.  See 310.10 for additional requirements related to notices sent via secure portal/applications.   B.  Development of the Appeal Case File