(Medicare Claims Processing Manual)

NOTE:  When the beneficiary preference is to have all documents converted into an accessible format, MACs shall make allowances for additional delivery time of the accessible format. The MAC shall also provide allowance for a delayed response as a result of a beneficiary having sought and received help from an auxiliary resource (such as a SHIP or senior center), on account of his or her disability, in order to be able to file an appeal (also see 240.2).   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  MAC 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.  These time  limits ma y be extended if good c ause for late filing is shown.  (See 240.1- 240.5.)  W hen a redetermination re quest appears to be  filed late, the MAC  makes a finding of good cause  using the guidelines in 240.2 through 240.4 bef ore taking any other action on the  appeal.   B. Extension of Time Limit for Filing a R equest for Redetermination  The time  limit f or filing a request for redetermination m ay be extended in cer tain situ ations.  G enerally, provider s, ph ysicians or  other suppli ers are expected to file appeal re quests on a time ly basis.  A re quest from a  provider , physician, or othe r suppli er to extend the  period for filing the request for redetermination should not be  routine ly granted and such requests warrant car eful examination.  F or a beneficiary request, more lenience should be  given.  Upon re quest by the party that has misse d the  filing deadline, the A/B MAC (A), (B), (HHH), or DME MAC  may extend the per iod for filing the request for redetermination.  The procedures for finding good c ause to excuse late filing ar e discussed below.  240.1 - Good Cause  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If an appeal request is f iled late, the applicable MAC  may extend the  time  limit f or filing an appeal if good cause is shown.  T he MAC  resolves the issue  of whether good cause exists b efore taking any other action on the appeal.  Whenever a MAC makes a finding for good cause for late filing, the MAC shall document the reason for that finding in the redetermination decision letter.  If no decision letter is issued (i.e., a decision fully favorable to the appellant is made, which currently does not require issuance of a redetermination decision letter), then the reason t he MAC  found th at good ca use exists f or late filing shall be documented in the redetermination  case file.   NOTE:  A finding by the MAC  that good cause  exists f or late filing for the redetermination doe s not m ean that the party is then excused from the  time ly filing rules for the reconside ration.  240.2 - Conditions and Examples That May Establish Good Cause for Late Filing by Beneficiaries (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A.  Conditions  Good c ause m ay be found when the  record c learly show s, or the  beneficiary alleges, that the de lay in filing was due  to one of the  follo wing:   Circumstan ces b eyond t he beneficiarys control, inc luding m ental or physi cal impairme nt (e.g., disabilit y, ex tended illn ess) or signifi cant c ommuni cation diffi culties;   Incorrect or in compl ete information about the  subject claim and/or appe al was furnish ed by offi cial sources (CMS, the  contra ctor, or the  Social Security Administration)  to the  beneficiary (e.g., a party is not notifi ed of he r app eal rights or a party r eceives inaccurate information r egarding a filing deadlin e);  NOT E:  Whenever a b eneficiary is not notifi ed of his/h er app eal rights or of the time  limits for filing, goo d cause must be  found.   Delay resulting from e fforts by  the beneficiary to secure  supporting ev idence, where the beneficiary did not realize that the  evidence could be  submitte d after filing the  request;   When destruction of or othe r damage to the  beneficiarys records w as responsible for the  delay in filing ( e.g., a fir e, natural disast er);   Unusual or una voidable  circumstan ces, the  natu re of w hich demonstrates that the b eneficiary could not reasonably be  expected to h ave been aware of the  need to file time ly;   Serious illn ess which prevented the  party  from  contacting the  contra ctor in pe rson, in w riting, or through a fri end, relative , or othe r person;    A death or s erious illn ess in his or he r imme diate  family;     A request was sent to a Gove rnment agency in good faith w ithin the  time  limit, and the  request did not reach the  appropriate  contractor until afte r the time period to file  a request expired; or   Delay due to additional time required to produce the beneficiarys Medicare documents (such as an MSN) in an accessible format (e.g., large print, Braille, etc.);     Delay as the result of an individual having sought and received help from an auxiliary resource (such as a SHIP or senior center), due to his or her disability, in order to be able to file the appeal.  B.  Examples  Follo wing are  exampl es of cases where good c ause for late  filing is found.  This list is illu strative only and not all -inclusive:   Beneficiary was hospitaliz ed and ex tremely ill, c ausing a de lay in filing;    Beneficiary is deceased.  Her husband, as r epresentative  of the  beneficiarys estate, died during the appeals filing p eriod.  R equest was then filed late  by the d eceas ed husband s executor;    The denial noti ce sent to the  beneficiary did not s pecify  the time  limit for fil ing for the  redetermination; and    The request was received after, but c lose to, the  last day  to file , and the be neficiary claims that the  request was submitte d time ly.  240.3 - Conditions and Examples T hat May Establish Good Cause for Late Filing by Providers, Physicians, or Other  Supp liers (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  In general, A/B MACs (A), (B), (HHH), and DME MACs s hould not routine ly find g ood c ause w hen a provider, physi cian or othe r suppli er submits an unt imely appeal request.  H owever, good c ause may  be found w hen the r ecord c learly show s, or the provider, physi cian o r other suppli er alleges and the  record does not ne gate, that the  delay in filing w as due  to one  of the  follo wing:   Incorrect or in compl ete information about the  subject claim and/or appe al was furnish ed by official sou rces (CMS, the  MACs, or the  Social Security Administration)  to the  provider, physi cian, or othe r suppli er; or   Unavoidable  circumsta nces that pr event ed the  provider, physi cian, or othe r suppli er from time ly filing a request for re determination.  Una voidable  circumstan ces e ncompass situations that are  beyond the  provider, phy sician or suppli ers control, suc h as major floods, fir es, tornados, and othe r natural c atastroph es.  NOT E:  Failure  of a bill ing company or othe r consultant ( that the  provider, physi cian, or othe r suppli er has retained) to timely submit appe als or othe r information is N OT grounds for finding good c ause for late  filing.  T he MAC do es not find good c ause w here the provider, physi cian, or othe r suppli er claims that la ck of busine ss offi ce manag ement skills or ex pertise c aused the  late filing.   240.4  Good Cause - Administrative Relief Following a Disaster  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10 - 01-19)  When a disaster occurs, whether natural or man -made, MACs shall anticipate both an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks.  For appeals purposes, as defined in this IOM, a disaster area is declared by the Federal Emergency Management Agency (FEMA).  In disaster situations, MACs that process appeals for beneficiaries, providers, and suppliers affected by a disaster shall exercise good cause in accorda nce with the regulations and follow the guidance below regarding how to process Fee -for-Service appeal requests in an area(s) declared by FEMA as a disaster area.     When a Presidential declaration occurs, the HHS Secretary may, under section 319 of the Public Health Service Act, declare that a Public Health Emergency (PHE) exists in the affected State.  Once a PHE is declared, section 1135 of the Social Security Act a uthorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements as determined necessary by CMS.  A. Definition of Disaster   A disaster is defined as any natural or man- made catastrophe (such as hurricane, tornado, earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, fire, flood, or explosion) which causes damage of sufficient severity and magn itude to partially or completely destroy medical records and associated documentation that could be needed and/or requested by the MACs in the course of the adjudication process, interrupts normal mail service (including US Postal delivery, overnight parce l delivery services, etc.), impacts ability to file appeals in a timely manner, and/or otherwise significantly limit the providers/supplier's daily operations.   A disaster may be widespread and impact multiple structures (e.g., a regional flood) or isolated and impact a single site only (e.g., water main failure).  The fact that a provider/supplier is located in a presidentially declared disaster area under the po wer of the Stafford Act is not sufficient in itself to justify administrative relief, as not all structures in the disaster area may have been subject to the same amount of damage.  Damage must be of sufficient severity and extent to compromise retrieval o f medical records.  The provider/supplier needs to state that they were impacted by the disaster.  B. Basis for Providing Administrative Relief  In the event of a disaster, MACs shall grant temporary administrative relief to any affected providers and suppliers for up to 6 months (or longer with good cause).  Administrative relief is to be granted to providers/suppliers/beneficiaries on a case -by-case basis in accordance with the following guidelines:   1. Situation: A provider/supplier/beneficiary in the affected area needs an extension to file a request for an appeal.  Action: The MAC shall grant an extension to request an appeal under the good cause exception.  Please see 42 CFR  405.942.  If the request is related to an overpayment, the MAC shall accept the request and stop recoupment immediately.  2. Situation: The MAC has requested or needs to request additional documentation for a pending appeal, but the provider/supplier/beneficiary has been impacted by a disaster.   Action: The MAC shall hold the request until the documentation can be obtained or submitted.  However, to the extent that the contractor can use other data sources that are available to substantiate payment for the claim, it should do so.  The CMS will waive the timeliness requirements for processing these appeals.