(Medicare Claims Processing Manual)

300.4 - Medical Consultants Used  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The parties are entitled to know the identity and qualifications of any consultant whose evidence the MAC used to support the initial claim determination or the redetermination.  If the MAC uses a consultant, it shall include the identity and qualifications of the consultant in the file for possible use by the ALJ, and for the appellants use upon request.  This applies to both external medical consultants and internal staff used to review the claim.  An example of this would be the name and title of the me dical consultant.   300.5 - Appeal Decision  Involving Multiple Bene ficiaries (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06 -13-19)  A. Appeals of  Overpayments Involving Multiple  Beneficiaries with a Single Account  Receivable   If an app ellant submits a r equest for re determination that in volves an o verpayment with a single a ccount receivable for c laims in volving multiple  beneficiaries, the  MAC shall issue  one decision l etter to the  appellant that in cludes info rmation sp ecific  to the  claims for e ach beneficiary.  The summa ry of fa cts, coverage, payment and liability  decisions for e ach beneficiarys claim(s) may be included as a s eparate attachment to the  deci sion letter. Sin ce ea ch beneficiary is a party  to the  appeal, subj ect to the  exception in 300.5.C  below, the MAC shall s end each beneficiary a copy of th eir own determination w ithout compromising the  privacy of othe r beneficiaries in the  appeal.  (Refer to I OM, 100 -06, M edicare Finan cial Manag ement M anual,  Chapter 6, section 460.1, for inst ructions on how  to count r equests that in volve multiple  beneficiaries).  B. Appeals Involving Claims of  Multiple Beneficiaries, Ot her than Overpayments with a Single Account  Receivable  If a party  files a request for re determination that in volves claims of multiple  beneficiaries that do not comprise  an o verpayment with a single  account r eceivable, the MAC may  process the app eal by  issuing a separate decision l etter for e ach beneficiary's claim(s) (i.e., as a split appe al), or the  MAC may  issue  a single  letter with atta chments for e ach separate c laim, w hichever is more  efficient.  Exampl e:  If a suppli er submits a single  appeal request involving unr elated claims for various be neficiaries that w ere denied on pr epayment review or through pr epayment edits, the MAC may  process the  appeal as a split and issue  separate l etters to the  suppli er-appellant, or the  MAC may  issue a single  letter with attachments for e ach claim.  I n either case, the be neficiary, as a party  to the appeal, must r eceive a copy of the decision l etter that p ertains to his or he r claims.   Exampl e:  If a suppli er submits a single  appeal request involving c laims r eviewed by a r ecovery auditor on a postpa yment basis, r esulting in ove rpayments (not e xtrapolat ed) processe d as s eparate a ccounts r eceivable, the MAC may  issue  either a single  deci sion l etter to the appe llant w ith atta chments for e ach claim, or separate decision l etters, w hichever is more e fficient.  T he beneficiary, as a party  to the  appeal, must r eceive a copy of t he decision l etter that p ertains to his or he r claims, subj ect to the  except ion not ed in 300.5.C  below.  C. Exception  to S ending Decision  Letters to B eneficiaries in Overpayment Cases  In an over payment case involving multiple  beneficiaries who h ave no financial liability prior to, a nd following the redetermination, the  MAC  mails the  decision l etter to the  appellant or the ir appoint ed representative.  In this situ ation, MACs a re not re quired to s end the  decision l etters to be neficiaries who ar e parties to the  redetermination ( see 42 CFR 405.956(a)(2) ).  Howe ver, if financial liability shifts from the  provider or suppli er to the  beneficiary, the MAC  issues a separate decision l etter to the  beneficiary that explains w hy he/she is lia ble, and explains the  subs equent appeal r ights available.  Exampl e: During a post payment review, claims for multiple  beneficiaries are initially  denied as b eing not medically reasonable  and necessa ry, and the  determination of liability  unde r section 1879 of the  Act finds the physi cian finan cially responsible  for the  denied services.  I f during the appe al, the  physi cian demonstrat es that a valid ABN  was issu ed for some  of the  services pro vided to certain b eneficiaries and finan cial responsibility  shifts from the  physi cian to those be neficiaries, the  MAC must issue  separate decision l etters to the  affected beneficiaries, but is not r equired to issue  separate decision l etters to those  beneficiaries whose liability  has not c hange d (i.e., liability  remains w ith the  physi cian).   310 - Redetermination - The First Level of Appeal  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07 -23-13)  A party dissatisfied with an initia l determination m ay request that the MAC  review its d etermination.  A redetermination is the  first level of appeal  after the initia l determination on P art A a nd Part B claims.  It is a second look a t the claim and suppor ting documentation a nd is m ade by an employee that did not ta ke part in the  initial d etermination.  I f an initia l determination is not m ade, ther e are no appeal rights on tha t claim (see 200.C  for a list of actions th at are not initi al determinations a nd the refore do not ha ve appeal rights).  The reviewer must c omply with, a nd is bound b y, all applicable  statutory and regulatory provisions.  The  reviewer may not ove rrule  the provisions of  the law or interpret them in a  way different than CMS; nor may the reviewer comm ent upon the  legality, constitution al or other wise, of any provision of  the Act, regulations, or CMS policy in the  review determination.  The  reviewer is also bou nd by all CMS-issued poli cies and procedures, including CMS rulings, Medicare manual instr uctions, c hange requests, n ational coverage determinations, a nd local c overage determinations.  The  reviewer must c onsider the applicabili ty of all CMS-issued poli cies and procedures to the  facts of  a given claim.  The  reviewer may not change the amount required to be  paid unde r the Physician Fee Schedule.    310.1 - Filing a Request for Redetermination  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  A request for redetermina tion must be  filed with the  contractor in w riting. The  request may be made by a party to the  appeal a s defined in 260 a nd/or  the partys representative as defined in 270. Appeal r equests submitte d electronically via a facsimile  or secure Internet por tal/application sh all be conside red to h ave been recei ved in w riting.  NOTE:  C ontracto rs are not re quired to utili ze a facsimile  and/or  a secure Internet po rtal/application f or performing a ppeals a ctivitie s.  Contracto rs may not require an appellant to file an appeal electronically (e.g., via facsimile  and/or  a secure Internet portal/application). Submission of  appeal re quests via  facsimile  or a portal/application sha ll be at the discretion of the  appellant.  C ontracto rs shall continue  to acc ept appeal requests in h ardcopy via mail.  A. W ritten Redetermination Requests Filed on Behalf of the Beneficiary  Someone othe r than an appoint ed representative may submit a  written request for redetermination on be half of a beneficiary. Persons who oft en act on be half of a b eneficiary in filing a r edetermination r equest include: the spous e, parent, child, sibling, ne ighbor or fri end. B eneficiary advocacy groups and Me mbers of C ongress may also submit a r equest for re determination on be half of a b eneficiary (see 310.1.A.1 for furthe r discussion on r equests submitte d by Members of Congress).  The contractor honor s the request for redetermination if  the request clearly shows the  beneficiary knew of or approved the submission of  the request for redetermination (e .g., the request is submitte d with a  written author ization from the  beneficiary or with the  beneficiarys MS N). How ever, if the contractor has information th at the redetermination re quest was not submitt ed at the request of the beneficiary, the contractor  does not c onduc t the redetermination unl ess and/or until it receiv es confirmation from the  beneficiary that the request was submitte d with the be neficiarys approval.  If a redetermination r equest is submitte d by an indi vidual w ho is not the  beneficiarys appoint ed representative , all w ritten noti ces related to the  appeal are s ent only to the  beneficiary, not the indi vidual making the  request for re determination.  I n addition, if the  contra ctor honors a r equest for re determination filed by som eone othe r than the  beneficiary or the beneficiarys appoint ed representative , the contra ctor should c ontact the beneficiary (or an appoint ed/authoriz ed representative  if appli cable) if furth er information is needed to process the r edetermination.   NOTE: An authoriz ed representative  is an indi vidual authoriz ed unde r State or othe r appli cable law  to act on be half of a  beneficiary in an appe al, and has all of the  rights  and r esponsibilitie s of a b eneficiary with respect to the  appeal.  An authoriz ed representative  does not need to s ecure an appointm ent of r epresentative  from the  beneficiary in orde r to file  an app eal or obtain/r eceive information r elated to t he appeal.  S ee 270.1.1 f or additional informa tion regarding authoriz ed representative s.  The person submitting the request does not a utom atically become  the representative until a nd unl ess an appointm ent of representative form or othe r written statement is c ompl eted (see 270 f or instructions on developing an inc ompl ete or absent appointm ent of representative).  There will be  circumst ances wh ere the mental and/or physical incapacity of the beneficiary becom es an issue. Based on all the  documented medical in formation a vailable, the contractor m ay decide  to allow the  person submitting  the request for redetermination t o act on be half of a beneficiary who is m entally or physically incapacitated. The  contractors decision, a s well as the b eneficiarys incapacita tion, should be  documented in the  file and suppor ted by relevant medical doc umentation.  1.  R equests for Redetermination Subm itted by Members of  Congress