(Medicare Claims Processing Manual)

Medicare Claims Processing Manual            Chapter 29 - Appeals of Claims Decisions            Table of Contents              (Rev. 12423; Issued:  12-20-23)  Transmittals for Chapter 29   110 -  Glossary  200 -  CMS Decisions Subject to the Administrative Appeals Process  210 -  Who May Appeal  210.1 -  Provider or Supplier Appeals When the Beneficiary is Deceased  220 -  Steps in the Appeals Process:  Overview  230 -  Where to Appeal  240 -  Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals  240.1 -  Good Cause  240.2 -  Conditions and Examples That May Establish Good C ause for Late Filing by B eneficiaries 240.3 -  Conditions and Examples That May Establish Good Cause for Late Filing by  Providers, Physicians or Other Suppliers  240.4 -  Good Cause   Administrative Relief Following a Disaster  240.5 -  Procedures to Follow When a Party Fails to Establish Good Cause  250 -  Amount in Controversy (AIC) Re quirements 250.1 -  Amount in Controversy General Requirements  250.2 -  Principles for Determining Amount in Controversy  250.3 -  Aggregation of Claims to Meet the Amount in Controversy 260 -  Parties to an Appeal  270 -  Appointment of Representative  270.1 -  Appointment of Representative - Introduction 270.1. 1 - Who May  be an Appoin ted or Authorized Representative 270.1.2 -  How to Make and Re voke a n App ointment 270.1.3 -  When and Where to Submit the A ppoin tment 270.1.4 -  Rights and Respons ibilities of a Representative 270.1.5 -  Duration of Appointment 270.1.6 -  Curing a D efective Ap pointment of Representative 270.1.7 -  Incapacitation or Death of B eneficiary 270.1.8 -  Disclosure of Indi vidually Identifiable Beneficiary Inf ormation t o an Ap pointed Representative 270.2 -  Assignment of Appeals Rights  270.2.1 -  Assignment of Appeal Rights -  Introduction 270.2.2 -  Who May be an Assignee  270.2.3 -  How to Make and Revoke a Transfer of Appeal Rights  270.2.4 -  When to Submit the Transfer of Appeal Rights  270.2.5 -  Where to Submit the Transfer of Appeal Rights  270.2.6 -  Rights of the Assignee of Appeal Rights  270.2.7 -  Duration of Transfer of Appeal Rights  270.2.8 -  Curing a Defective Transfer of Appeal Rights  270.2.9 -  Disclosure of Indi vidually Identifiable Beneficiary Inf ormation t o Assignees  270.3 -  Medicare Secondary Payer (MSP) Specific Limitations or Additional Requirements with  Respect to the Appointment of Representatives  280 -  Fraud and Abuse  280.1 -  Fraud and Abuse - Authority 280.2 -  Inclusion and Consideration of Evidence of Fraud and/or Abuse  280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed  280.4 -  Responsibilities of Adjudicators  280.5 -  Requests to Suspend the Appeals Process  280.6 -  Continuing Appeals of Providers, Physicians, or Other Suppliers Who Are Under Fraud or Abuse Investigations  280.7 -  Appeals of Claims Involving Excluded Providers, Physicians, or Other Suppliers  290 -  Guidelines for Writing Appeals Correspondence  290.1 -  General Guidelines  290.2 -  Letter Format  290.3 -  How to Establish Reading Level  290.3.1 -  Writing in Plain Language  290.4 -  Required Elements in Appeals Correspondence  300 -  Disclosure of Information 300.1 -  General Information  300.2 -  Disclosure of Information to Third Parties  300.3 -  Fraud and Abuse Investigations  300.4 -  Medical Consultants Used 300.5 -  Appeal Decision Involving M ultiple Bene ficiaries 310 -  Redetermination -  The First Level of Appeal  310.1 -  Filing a Request for Redetermination  310.2 -  Time Limit for Filing a Request for Redetermination  310.3 -  Reporting Redeterminations on the Appeals Report  310.4 -  The Redetermination  310.5 -  The Redetermination Decision  310.6 -  Dismissals  310.6.1 -  Dismissal Letters 310.6.2 -  Model Dismissal Notices            310.6.3  Processing Request to Vacate Dismissals     310.7 -  Medicare Redetermination N otice (For Pa rtly or Fully Unfavorable Redeterminations) 310.8 -  Medicare Redetermination N otice (for Fully Favorable Redeterminations) 310.9 -  Effect of the Redetermination  310.10 -  System and Processing Requirements for Use of Secure Internet Portal/Application to Support Appeals Activities  310.11 -  Effectuation of the Redetermina tion Decision 310.12 - QIC R emands 320 -  Reconsideration -  The Second Level of Appeal  320.1 -  Filing a Request for a Reconsideration  320.2 -  Time Limit for Filing a Request for a Reconsideration  320.3 -  MAC  Responsibilities -  General  320.4 -  QIC Case File Development  320.5 -  QIC Case File Preparation  320.6 -  Forwarding QIC Case Files  320.7 -  QIC Jurisdictions  320.8 -  Tracking Cases  320.9 -  Effectuation of Reconsiderations  330 -  Administrative Law Judge ( ALJ) Hearing or Attorney Adjudicator Review at Office of Medicare            Hearings and Appeals (OMHA) - The Third Level of Appeal  330.1 -  Requests for an ALJ H earing 330.2 -  Forwarding Requests to OMHA  330.3 -  Review and Effectuation of  OMHA D ecisions 330.4 -  Effectuation Time Limits & Responsibilities 330.5 -  Duplicate OMHA D ecisions 330.6 -  Payment of Interest on OMHA Decisions 340 -  Departmental Appea ls Board - Appeals Counc il - The Fourth Level of Appeal 340.1 -  Recommending Agency Referral of OMHA Decisions or Dismissals  340.2 -  Effectuation of Appeals Council Orders and Decisions  340.3 -  Requests for Case Files  340.4 -  Payment of Interest on Appeals Council Decisions  345 -  U.S. District Court Review -  The Fifth Level of Appeal  345.1 -  Requests for U.S. District Court Review by a Party 345.2 -  Effectuation of U.S. District Court Decisions  345.3 -  Payment of Interest of U.S. District Court Decisions  350 -  Workload Data Analysis 360 -  Managing Appeals Workloads  360.1 -  Standard Operating Procedures  360.2 -  Execution of Workload Prioritization 360.3 -  Workload Priorities     110 - Glossary  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Adjudicator  The entity responsible for making the decision at any level of the Medicare claim decision making process, from initial determination to the final level of appeal, on a specific claim.    Administrative Law Judge (ALJ)  Adjudicator employed by the Department of Health and Human Services (HHS), Office of Medicare Hearings and Appeals (OMHA) that holds hearings and issues decisions related to level 3 of the appeals process.    Affirmation -  A term used to denote that a prior claims determination has been upheld by the current claims adjudicator. Although appeals through the OMHA level are de novo, CMS and its contractors often use this term when an adjudicator reaches the same conclusion as  that in the prior determination, even though he/she is not bound by the prior determination.    Amount in Controversy (AIC) -  The dollar amount required to be in dispute to establish the right to a particular level of appeal.  Congress establishes the amount in controversy requirements.    Appeals Council  The Medicare Appeals Council (herein Appeals Council), a division within the  Departmental Appeals Board, provides the final level of administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment. (See also Departmental Appeals Board.)    Appellant -  The term used to designate the party (i.e., the beneficiary, provider, supplier, or other person showing an interest in the claim determination) or the representative of the party that has filed an appeal.  The adjudicator determines if a particular appellant is a proper party or representative of a proper party.    Applicable plan   Applicable plan means liability insurance (including self -insurance), no- fault insurance, or a workers' compensation law or plan.    Appointed representative  The individual appointed by a party to represent the party in a Medicare claim or claim appeal.    Assignee  (1) With respect to the assignment of a claim for items or services, the assignee is the supplier who has furnished items or services to a beneficiary and has accepted a valid assignment of a claim;    OR    (2) With respect to an assignment of appeal rights, an assignee is a provider or supplier who is not already a party to an appeal, who has furnished items or services to a beneficiary, and has accepted a valid assignment of the right to appeal a claim exec uted by the beneficiary.    Assignment of appeal rights  The transfer by a beneficiary of his or her right to appeal under the claims appeal process to a provider or supplier who is not already a party, and who provided the items or services to the beneficiary.    Assignor  A beneficiary whose provider of service or supplier has taken assignment of a claim, or assignment of an appeal of a claim.    Attorney Adjudicator - A licensed attorney employed by OMHA with knowledge of Medicare coverage and payment laws and guidance, authorized to take the actions provided for in 42 CFR 405 subpart I on requests for ALJ hearing and requests for reviews of QIC dismissals.    Authorized representative  An individual authorized under State or other applicable law to act on behalf of a beneficiary or other party involved in the appeal. The authorized representative will have all of the rights and responsibilities of a beneficiary or party, as applicable, throughout the appeals process.    Beneficiary  Individual who is enrolled to receive benefits under Medicare Part A and/or Part B.    Contractor -  An entity that contracts with the Federal government to review and/or adjudicate claims, determinations and/or decisions.    Date of Receipt  A determination, decision or notice is presumed to have been received by the party five days from the date included on the determination or decision, unless there is evidence to the contrary.    NOTE:  Throughout Chapter 29, reference to day or days means calendar days unless otherwise specified.    Departmental Appeals Board (DAB) Review - The DAB provides impartial, independent review of disputed decisions in a wide range of Department of Health and Human Services programs under more than 60 statutory provisions.  The Medicare Appeals Council (herein Appeals Council), a division within the Departmental Appeals Board, provides the final level of administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment. (See section 340 in this chapter.)    De Novo -  Latin phrase meaning anew or afresh, used to denote the manner in which claims are adjudicated in the administrative appeals process.  Adjudicators at each level of appeal make a new, independent and thorough evaluation of the claim(s) at issue, and are not bound by the findings and decision made by an adjudicator in a prior determination or decision.    Decisions and Determinations - If a Medicare appeal request does not result in a dismissal, adjudication of the appeal results in either a determination or decision.  There is no apparent practical distinction between these two terms although applicable regulations use the terms in distinct contexts.    A decision that is reopened and thereafter revised is called a revised determination.    Dismissal -  An action taken by an adjudicator when an appeal will not be conducted as requested.  A request for appeal may be dismissed for any number of reasons, including:    1. Abandonment of the appeal by the appellant;  2. A request is made by the appellant to withdraw the appeal;  3. A determination that an appellant is not a proper party;  4. The amount in controversy requirements have not been met; and  5. The appellant has died and no one else is prejudiced by the claims determination.