(Medicare Claims Processing Manual)

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.   3. Situation: A request for an appeal filed by an appointed representative on behalf of a party contains a missing or defective appointment instrument and the party is in the affected area.  Action: The contractor shall process the request and attempt to obtain the corrected appointment instrument.  If the corrected appointment instrument is not received by the end of the appeals adjudication period, contractors shall send the redetermination decision letter to the appellant party and any other party to the appeal, but not to the individual attempting to act as the representative.  4. Situation: A MAC receives a request for redetermination from a provider/supplier/beneficiary in the affected area and the request is missing some of the required elements to make it a valid request.  However, the MAC has information in the shared systems that would a llow it to identify the missing element(s).   Action: The MAC shall accept and process the request, using information already available to it via the shared system.    C. Verification  In the case of complete destruction of medical records where no backup records exist, MAC Appeal Units and QICs shall accept an attestation that no medical records exist and consider the services covered and correctly coded.   240.5 - Procedures to Follow When a  Party Fails to Establish Good Cause (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If a party  files an untim ely request for re determination a nd ther e is insu fficient or no e xplanation f or the delay or no othe r evidence that establish es the reason f or late filing, the MAC dismisse s the redetermination request.  The  MAC  explains in the  dism issal letter that the party  can:  1 ) request that the MAC  vacate the dismiss al by providing an explanation f or the late filing to the  MAC  within 6 months of  the dismissa l of the redetermination request; and 2) request that the  QIC review the MACs dismissal a ction by filing a r equest with the  QIC within 60 d ays of the  date of receipt  of the  dismissal notice.   If an explanation or  othe r evidence is submitte d within 6 months from the  dismissa l that contains su fficient evidence or other documentation th at supports a finding of good cause  for late filing, the MAC  (as applicable) makes a favorable good cause  determination.  Once it ma kes a fa vorable good caus e determination, it c onsid ers the appeal to be  time ly filed and pr oceeds to vacate  its p rior dismissa l and performs a redetermination (see 310.6.3 Processing Requests to Vacate Dismissals).   The closed date is the  date of the dismiss al, and the  dismiss al is reported on the Contra ctor R eporting of Operational  Workload Data (CROWD) in the  appropriate  appeals report forms ( Carriers App eals Report Form CMS-2590, M onthly I ntermediary  Part A  and Part B App eals R eport Form C MS-2591, or M onthly Statistic al Report on I ntermediary  and Carrier Part A and Part B App eals A ctivity  Form C MS-2592) .  The closed date and date of dismissal are also captured in the Medicare Appeals System (MAS) and can be appropriately reported on by the Part A MACs.     250 - Amount in Controversy (AIC) Requirements (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation:07 -23-13)  This section is informational only since the amount in controversy requirements only apply to the ALJ and Federal court levels.  Section 1869 (b)(1 )(E) of the Act established amount in controversy threshold amounts for ALJ hearing requests and judicial review at $100 and $1,000, r espectively.  As ame nded by section 940 of t he MMA , this amount will be adjusted annua lly.  In order to continue an appeal follow ing the QIC reconsideration le vel, a party must have an am ount remaining in controversy that meets the threshold requirements.  250.1 - Amount in Controversy General Requirements  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Each c alendar year, the dollar threshold f or the AIC requirement for ALJ hearing requests or judi cial review will be  recalculated to r eflect the percent age increase in the  medical care compone nt of the consumer price index for all urban consum ers (U.S. city average) for July 2003 to the  July preceding the year involve d. Any amount tha t is not a  multiple  of $10 will be  round ed to the  nearest multiple  of $10.  C hanges to the  amount in controversy threshold amounts ar e publishe d annually in the  Federal Register as per 42 CFR 405.1006( b).  Current AIC amounts, along with a link to the current Federal Register AIC Notice, c an be  found on the CMS.gov website at:  https://www.cms.gov/Medicare/Appeals -and-Grievances/OrgMedFFSAppeals/OMHA -ALJ-Hearing.html   250.2 - Principles for Determining Amount in Controversy  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  As part of the requirements for a hearing or review bef ore OMHA, a  party to a proceeding must mee t the AIC provisions a t 42 C FR 405.1006, in cluding the threshold a mount, a s adjust ed, in accor dance with 42 CFR 405.1006(b) .    The AIC is computed as the actual amount charged the individual for the items and services in question, reduced by  (a) Any Medicare payments already made or awarded for the items or  services; and  (b) Any deductible and coinsurance amounts that may be collected for the items or services.   In such cas es where payment is ma de for items o r services und er section 1879 of  the Act or unde r 42 C FR 411.400 o r the liability of the beneficiary is limite d unde r 42 CFR411.402, the A IC is comput ed as the amount tha t the beneficiary would ha ve been charged for the items or s ervices in que stion if  those expenses were not pa id unde r 42 C FR 411.400 or that the liability was not limite d unde r 42 C FR 411.402, re duced by any deductible and coinsurance amounts that may be collected for the items or services.   When a matter involves a provider or supplier termination of Medicare -covered items or services that is disputed by a beneficiary, and the beneficiary did not elect to continue receiving the items or services, the amount in controversy is calculated in acc ordance with 42 CFR 405.1006(d)(1) , except that the amount charged to the individual and any deductible and coinsurance that may be collected for the items or services are calculated using the amount the beneficiary would have been charged if the beneficiary had received the items or services the beneficiary asserts should have been covered based on the beneficiary's current condition, and Medicare payment were not made for the items or services.   When an appeal involves an identified overpayment, the amount in controversy is the amount of the overpayment specified in the demand letter for the items or services in the disputed claim. When an appeal involves an estimated overpayment amount determined through the use of statistical sampling and extrapolation, the amount in controversy is the total amount of the estimated overpayment determined through extrapolation, as specified in the demand letter.   For appeals filed by beneficiaries challenging only the computation of a coinsurance amount or the amount of a remaining deductible, the amount in controversy is the difference between the amount of the coinsurance or remaining deductible, as determined by the contractor, and the amount of the coinsurance or remaining deductible the beneficiary believes is correct.   For appeals of claims where the allowable amount has been paid in full and the appellant is challenging only the validity of the allowable amount, as reflected on the published fee schedule or in the published contractor -priced amount applicable to the ite ms or services in the disputed claim, the amount in controversy is the difference between the amount the appellant argues should have been the allowable amount for the items or services in the disputed claim in the applicable jurisdiction and place of serv ice, and the published allowable amount for the items or services.   After processi ng the reconsideration, the  QIC shall send w ritten noti fication to a ll parties.  This noti ce shall include any information concerning the parties rights to a n ALJ hearing, including the  applicable  AIC requirements and aggregation provisions.   250.3 - Aggregation of Claims to Meet the Amount in Controversy  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A party appealing a QIC reconside ration to the  ALJ level that do es not m eet the  AIC threshold re quirements may, und er certain circumst ances, aggregate claims to meet the  requirements set forth in 42 C FR 405.1006.  Either an individua l appellant or multiple  appellants m ay aggregate two or  more claims to meet the  AIC requirements for an ALJ hearing if -  a) The claims w ere previous ly reconside red by a QIC;  b) The request for ALJ hearing lists a ll of the claims to be  aggregated and is f iled within 60 da ys after receipt of  all the reconside rations be ing appealed; and  c) The ALJ determines that the claims th at a single appellant seeks to a ggregate involve the  delivery of simila r or related services, or  the claims th at multiple  appellants seek to a ggregate involve  common issue s of law and fact. Part A a nd Part B claims m ay be combine d to m eet the  AIC requirements.  In cases where claims a re escalated from the  QIC level to the  ALJ level (if parties have met all oth er requirements), aggregating c laims ma y proceed unde r certain circumstances.  Eith er an individua l appellant or multiple  appellants m ay aggregate two o r more claims to meet the  AIC for  an ALJ hearing if -  (a) The claims w ere pending before the QIC in conjunc tion with the  same request for reconside ration;  (b) The appellant(s) requests aggregation of  the claims to the  ALJ level in the  same re quest for escalation; a nd  (c) The ALJ determines that the claims th at a single appellant seeks to a ggregate involve the  delivery of simila r or related services, or  the claims th at multiple  appellants seek to a ggregate involve  common issue s of law and fact.  Part A a nd Part B claims may be combine d to m eet the  AIC requirements.  When the  appellant(s) seeks to a ggregate claims i n a request for an ALJ hearing, the appellant(s) must -  (a) Specify all of the claims the  appellant(s) seeks to aggregate; and  (b) State why the appellant(s) believes that the claims involve  common is sues of law and fact or  delivery of simila r or related services.  260 - Parties to an Appeal  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)