(Medicare Claims Processing Manual)

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  Alaska, Am erican Samo a, Arizona, California, Guam, Hawaii, Idaho, I llinois, Indiana, Iowa, Kansas, Kentucky , Michigan, Minnesota, M issouri, Montana, N ebraska, Nevada, North Da kota, Northern M ariana Islands, Ohio, Or egon, South Dakota, Utah, Washington, Wisconsin and Wyoming and Mutua l of Omaha claims wh ere the service was rendered in on e of the above  liste d States.  Chain Providers (including ESRD) - the St ate where the MAC processed the  claim.  F or providers who pr eviously submitte d claims to Mutu al of Omaha (currently processe d by WPS), the jurisdiction c ontinue s to be  the St ate where the service was rendered.  Foreign claims- Western Mexico, Canadian Provinces of  Ontario, Saskatchewan, Alber ta, Manitoba , British C olumbi a, Vancouve r, and Yukon Territories.   B.  Part B  and DME QIC Jurisdictions  There is one  DME Q IC jurisdiction assigned to pr ocess a ll reconsiderations of  DME  claims for all state s and t erritori es.  Th ere are two Q IC jurisdictions f or Part B claims, a  North and a South jur isdiction. Refer to the t able below.    Jurisdiction Normal States Exceptions  Part B South Jurisdiction  Alabama, Ar kansas, Colorado, Florida, Georgia, L ouisiana, Mississ ippi, New Mex ico, North C arolina, Oklahoma, Pue rto Ri co, South C arolina, Tennessee, T exas, Virginia, West Virginia, Virgin Islands.  Note: Railroad Retirement Board recon siderations are also i ncluded in this workload jurisdiction. Part B North Jurisdiction  Alaska, Am erican Samo a, Arizona, C alifornia,  Connectic ut, D elaware, Guam, Haw aii, Idaho, Illinois, I ndiana, Iowa, Kansas, Kentucky , Maine, Maryland, M assachusetts, Michigan, M innesota, Missouri, M ontana, Nebraska, Nevada, New Hampshir e, New Jersey, New York, North Da kota, Northern M ariana Islands, Ohio, Or egon, Pennsylvania, Rhode  Island, South Da kota, Utah, V ermont, Washington, Washington DC, Wisconsin and Wyoming.   DME QIC Jurisdiction  All states and territories    320.8 - Tracking Cases  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Contracto rs shall track all incoming requests for c ase fil es from the  QICs.  The contractor shall keep a  record of the date of the request, the  format of the request (e.g., telephone , emails, electronic) the date the case file was forwarded to the QIC, and the  means of  forwarding (e.g. Fed Ex Same Day, Fed Ex overnight, U PS 2 da y).  If a courier service is used, the  contractor shall utili ze the courier services tracki ng mechanism to k eep a  record of the date of receipt at the Q IC.  Contracto rs shall track all mis filed reconsid eration re quests to e nsure receipt at  the proper QIC.  The QIC will s end the  MAC  or DME MAC  an acknowl edgement of receipt of  any misfiled   requests.  C ontracto rs shall keep a record of the date of receipt of  the misfiled request, the  date it was forwarded to the  QIC, the means of  forwarding, and the  date of the QICs acknowl edgement.  Contracto rs shall track all requests from the  QIC for effectuation.  The  contractor  shall ma ke a recor d of the date of receipt of  the QICs request for effectuation a nd confirm receipt of  the effectuation noti ce with the  QIC.  The  contractor  shall also track the  date of effectuation ( i.e., issue  payment).  320.9 - Effectuation of Reconsiderations  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  In many cases, the  QIC's decision will re quire an effectuation action on the  MACs p art.  The  MAC  does not e ffectuate based on corresponde nce from a ny party of the rec onside ration.  It takes an effectuation a ction only in respons e to a formal decision a nd R econsid eration Effectuation Noti ce from the  QIC.  "Effectu ate" means f or the MAC  to adjust the claim and issue  a payment or to change liability.  If the QIC's decision is fa vorable to the  appellant and gives a specific amount to be  paid, the  MAC  effectuates within 30 cal endar days of the date of receipt of the e ffectuation noti ce from the  QIC.  NOTE:  CMS does not a nticipate that QICs will sp ecify an amount to be  paid in reconside ration noti ces.  If the decision is fa vorable, but the  payment amo unt must be  comput ed or r ecomput ed, it effectuat es the decision w ithin 30 da ys aft er the payment amount is de termined.  The  amount must be  comput ed as soon a s possibl e, but no l ater than 30 cal endar days after the date of receipt of  the QIC's effectuation  notice.  The  receipt of  effectuation in formation sha ll be reported to the a ppropriate QIC.  If the QICs decision is unfa vorabl e, but the re is a change  in liability, the  MAC e ffectuat es within 30 c alendar da ys of receipt of the  QICs effectuation noti ce.  330 - Administrative Law Judge (ALJ) Hearing or Attorney Adjudicator Review at the Office of Medicare Hearings and Appeals (OMHA) - The T hird Level of Appeal (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A party to a Q IC reconside ration m ay request a hearing before an ALJ if the party files a written request for an ALJ hearing within 60 da ys after receipt of  the notice of the QICs recon sideration a nd the a mount in c ontroversy requirement is me t*.  A  party who f iles a time ly appeal b efore a QIC and whose  appeal continues to be  pending before a QIC at the end of the QICs decision -making tim eframe has a right to a  hearing before an ALJ if the party files a written request with the  QIC to e scalate the appeal to the  ALJ level after the adjudication per iod expires and the  QIC does not issue  a final action with in 5 da ys of receivi ng the request for escalation.  A par ty wishing to escalate an appeal must a lso m eet the  amount in c ontroversy requirement*.  A p arty to a Q ICs dismissa l of a request for reconside ration ha s a right to ha ve   the dismiss al reviewed by an ALJ or attorney adjudicator if the party meets the  amount in controversy requirement*.  *See 250 for A IC information. T he current amount in c ontrove rsy requirements can be  found on the  CMS.gov c laims app eals webpage:  http://www.cms.gov/Medicare/Appeals -and-Grievances/OrgMedFFSAppeals/Downloads/AppealsProcessFlowchart -FFS.pdf   330.1 - Requests for an ALJ Hearing (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Where P arties File Requests  To re ceive an ALJ hearing, a party to the  QICs reconsideration must file a written request for an A LJ hearing with the  entity specified in the  QICs reconside ration.  The  appellant must also send a copy of the request for hearing to the  other parties.  Fa ilure to do so will toll the  ALJs 90- day adjudi cation d eadline  until all parties to the  QIC reconsideration r eceive  notice of the requested ALJ hearing.  Also, if  the request for hearing is timely filed with a n entity other than the  entity specified in the  QICs reconsideration, the  ALJs deadline  for decidi ng the appeal b egins on the da te the entity specified in the  QICs reconside ration ( i.e., the  appropriate OMHA o ffice) receives the request for hearing.  The QICs will sp ecify the appropriate OMHA office as the filing location f or ALJ hearing requests.  B.  Timely Filing Requirements  A party must f ile an ALJ request within 60 da ys of the date of their receipt of  the QICs decision. I t is p resumed tha t the appellant received the  QICs decision within f ive days of the date of the Q ICs decision, unl ess there is a reasonable show ing by the appellant to the  contrary.  C.  Co ntent of the Request  The request for an ALJ hearing must be  made in writing.  The  request must include all of the followin g:  1.   The  name, address, and Medicare numbe r of the beneficiary whose  claim is being appealed,  2.   The  name and address of the appellant, whe n the appellant is not the  beneficiary,  3.   The  name and address of the designated representative, if any,  4.   The  document control number assigned to the  appeal b y the QIC, if any,    5.   The  dates of service,  6.   The  reasons the  appellant disagrees with the  QICs reconside ration or  othe r determination be ing appealed, and  7.   A st atement of any additiona l evidence to be  submitte d and the  date it will be  submitte d.  For the conve nience of parties, OMHA p rovides forms th at may be used to re quest a Medicare ALJ hearing.  It is not n ecessa ry, however, that this f orm be  used to make a written request.   The request for hearing form OMHA -100:     https://www.hhs.gov/sites/default/files/OMHA -100.pdf                                    In addition, the form OMHA 100A is used as an attachment to form OMHA 100 to identify multiple beneficiaries or enrollees associated with a single request for an ALJ hearing or a review of dismissal.  The direct link to form OMHA -100A:    https://www.hhs.gov/sites/default/files/OMHA -100A -Multiple -Claim-Attachment.pdf    The link to OMHAs webpage containing all forms:    https://www.hhs.gov/about/agencies/omha/filing- an-appeal/forms/index.html   To request that OMHA make a decision  without a hearing based only on the information thats in the appeal record, an appellant must submit the information required for an ALJ hearing request and one of these:    The Waiver of Right to an Administrative Law Judge (ALJ) Hearing form (Form OMHA -104) available at https://www.hhs.gov/sites/default/files/OMHA -104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf ; or   A written request stating that you dont wish to appear before an ALJ at a hearing (including a hearing held by phone or video- teleconference), and explaining why you decided to waive the hearing.   Even if a waiver of hearing is requested, a hearing may still be held by an ALJ if the other parties in the case dont also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide the case.