(Medicare Claims Processing Manual)

 For long letters, headings should be  used to break i t up (e .g., DECISION, BACKGR OUN D, R ATIONA LE);   If procedure codes are cited, the  actual name of the procedu re must be  associated with the  code;   Span dates may not be  used for 1 da y of service; and   The MAC  should no t use all capit al letters.  Letters that contain all capital letters appear impersonal and comput er generated.  Refer to 300.5 f or instructions on how to ha ndle cases involving multiple  beneficiaries, inc luding overpayment cases involving multiple  beneficiaries.  290.3 - How to Establish Reading Level  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The MMA requires that appeals correspondence be written in a manner calculated to be understood by beneficiaries.  MACs shall write appeals correspondence that is understandable to beneficiaries.  The purpose of this section is to provide some guidance to MACs on writing letters that are easy for beneficiaries to understand.  To achieve this goal, MACs shall:  (1) Write in plain English/plain language with a clear, simple, conversational writing style with good communication of key points.   (2) Get reading levels of letters as low as you can without losing important content or distorting the meaning and without sounding condescending to the reader.   NOTE:  This requirement does not apply to providers.  MACs can use a cover sheet for the beneficiary, when sending a copy of the decision.   290.3.1 - Writing in Plain Language  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The following are some tips to help MACs  to write letters in plain language:   Include definitions or explain terms you must use that are not familiar with your intended audience.    Use heading, subheadings, or other devices to signal what's coming next.  Labels for sections, headings, and subheading should be clear and informative to the intended audience.    Write in an active voice and in a conversational style.  For example, conversational style uses contractions (I'd instead of I would) and informal vocabulary (find out instead of determine).    Use a friendly and positive tone.    Use words that are familiar to your intended audience.  Shorter words tend to be more common, and they are generally preferable.  For example, use doctor instead of physician.  Pay back instead of reimburse.  Can get instead of eligible.  There are excepti ons.  For example, access is a short word, but it is health care jargon that is hard for many consumers to understand.  Organization is a five -syllable word, but is probably familiar to most readers.    When a term is best known to your intended audience by its acronym, use the acronym and spell out the word that it represents in parenthesis with the letters that form the acronym in bold.  For example: PCP (Primary C are P rovider).    Be on alert for words that are abstract or vague, or that may mean different things to different people.  Replace these words with more specific words to be sure your readers understand the key messages.   Keep your sentences simple and direct.  Most should be reasonably short; about eight to ten words per sentence for most sentences.  When sentences are long, the main point gets lost in all the words.  Active voice makes the style more direct.    Vary the length of your sentences.  Somewhat longer, natural -sounding sentences of about 12 to 15 words can effectively break up the choppy effect of using many short sentences.    Paragraphs should be relatively short.  Short paragraphs are more inviting to your reader and give the visual appearance of being easier to read.    Use simpler words rather than technical terms whenever you can without losing the content or distorting the meaning.  Sometimes it's important to use a technical term, such as the words mammogram, or cholesterol.    Appearance should be appealing at first glance.  Pages should be uncluttered with generous margins and plenty of white space.   The graphic design should use contrast, indentation, bullets, and other devices to signal the main points and make the text easier to skim.   Use a large type and spacing between lines.   290.4 - Required Elements in Appeals Correspondence  (Rev. 2926, Issued: 04- 11-14, Effective: 07 -14-14, Implementation: 07- 14-14)  The following should be  used in a ll appeals c orresponde nce:   The name of the beneficiary/provider /physician/suppli er to whom the  letter is addressed rather than Dear Sir/Madam;"   Corresponde nce is id entified by either the date on w ritten corresponde nce or the d ate the written correspondence was received;   The name of the provide r, physician or suppli er as well as the date(s) of service;   When appropriate, an explanation in l etters to be neficiaries, explaining  why he/she is being sent a letter if the appeal came from the  provider , physician or other suppli er;   The appeal determination/decision is pl aced in the  beginning of the letter;   Explicit rationale that describes why the items or  services a t issue  do not  meet M edicare guidelines.  M erely stating that an item or service is not m edically reasona ble and ne cessa ry unde r 1862( a)(1) or not m edically reasonable and necessa ry unde r Medicare guidelines does not pr ovide  any rationale. The rationale should inc lude a description of  the logic that led to the decision, re ferences used to suppor t the decision, a nd other information th at is re levant to suppor t the decision in the  case;   When the  appeals c orresponde nce includes Me dicare statutory citations, t hey must be  related to the decision in l aymans terms.  The  statutory cite is liste d as a parenthe tical at the end of the sentence.  For example, inst ead of  beginning a sentence with,  1879 of  the Social Security Act states that..., the sentence should st art with  Under Medicare law, suppliers must...( 1879 of  the Social Security Act);   Whenever the person is to recei ve some  further respons e, such as an MSN (if available), an estima ted time frame as to wh en he/she will recei ve it is p rovide d;   Telephone  numbe r on a ll correspond ence for addition al que stions;    What, if anything, must be  done  next, and by whom;   As appropriate, the results of any consult ations with pr ofession al medical staff;   When applicable, a statement advising the appellant that upon w ritten request the MAC  will provide  them copies of regulations, st atutes, and guidelines used in m aking the determination;   For appeals, if  the redetermination is p artially or whol ly favorable, an explanation a bout w hy the new determination is di fferent fro m the  previous de termination; a nd   The corresponde nce must be written in a  clear manner and with a  custom er- friendly tone.  300 - Disclosure of Information  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  300.1 - General Information  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  The basis for policy governing the disclosure and confidentiality of information collected by the contractor is 1106 of the Act, the Departments Public Information regulations, as well as the Privacy Act, and the Freedom of Information Act.  In general, all information relating to an individual is confidential except as provided by regulation.  In the interest of an appellants right to due process, there are situations where information may be disclosed.  The CMS regulations implementing 1106 of the Act can be found at 42 CFR Part 401, Subpart B . (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 6.)   In addition, 1106 in title XI of the Act provides penalties for violation of the provisions concerning confidentiality of information.  Activities prohibited under the provisions of the Act include, but are not limited to, making false and fraudulent statements, fraudulent  concealment of evidence affecting payment benefits, false impersonation of another individual, misuse or conversion of payments for use of another, and improper disclosure of confidential information. (See the Medicare Program Integrity Manual 100- 08.)  300.2 - Disclosure of Information to Third Parties  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  If a beneficiary wishes to have his/her information disclosed to a third party without appointing that individual as a representative, this can be accomplished by the beneficiary or third party providing written authorization to the MAC for the release of the information.  The written authorization must contain a signature of the beneficiary and an explanation of the type of information the beneficiary agrees to release to the individual.  An example of this type of situation is where a beneficiary has aske d a Member of Congress for assistance with his/her appeal.  In this case, it may be necessary for the Member of Congress to receive the decision; however the Member of Congress does not wish to accept the responsibility associated with being the beneficiar y's appointed representative or the beneficiary does not wish to appoint the Member of Congress as his/her representative.  See 310.1 for more information on requests for redetermination submitted by Members of Congress.  If the beneficiary wishes to appoint a representative, MACs should refer to 270.  300.3 - Fraud and Abuse Investigations  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Any and all evidence used by the A/B MAC (A), (B), (HHH), or DME MAC  to arr ive at a determination or  decision sha ll be pl aced in the  appeals c ase file (copies are acceptabl e).  Information in the  case  file shall be made available to an appellant upon re quest.  Th erefore, the MAC  shall be aware that information pl aced in the case file is accessible  to an appellant.  The  UPIC sh all also under stand tha t the MAC  may not c onsid er any evidence that has not been m ade a part of the case  file.  The UPIC a nd the  MAC  shall therefore exercise  discretion whe n deciding whe ther to pl ace any of the following information into the  appeals cas e file:   The impetus be hind a  fraud and abuse inve stigation;   The name of the beneficiary or any other person lodg ing the compl aint th at triggers the fraud and abuse inve stigation;   Notes or transcripts of  beneficiary interviews resulting from a  fraud and abuse inv estigation;   Records or  information c ompil ed for law enforcement pur poses dur ing a fraud and abuse investigation; or   The name of a confidential source( s) when confidentiality has been promised by CMS in re turn for coope ration in a  fraud and abuse inve stigation.  Where the MAC  relies upon a ny of the above  information in or der to deny a claim or  to re nder a less than fully favorable determination or  decision, the n an appellant ha s a due process right to re view this information.  If information is ke pt out of  an appeals case file for confidentiality reasons, it  may not be  relied upon t o ma ke a coverage decis ion or de ny or reduce pa yment.  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