(Medicare Claims Processing Manual)

a. The decision letter, if applicable, is mailed to the parties.  If the redetermination is processed via a CMS approved secure Internet portal/application, it shall be considered complete on the date the electronic redetermination notice is transmitted to  the appellant through the secure Internet portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure Internet portal/application.  See 310.10 for additional requirements related to notices sent via secure portal/ applications, a nd  b. The actions to initiate the adjustment action in the claims processing system are taken.  When the adjustment action is completed, this action must be included on the next scheduled release of the MSN/RA.  Appropriate follow -up action should be taken to ensure that the adjustment action results in the issuance of proper payment.  3. For withdrawals and dismissals, the date the dismissal notice is mailed. If the redetermination is processed via a CMS approved secure Internet portal/application, it shall be considered complete on the date the notice is transmitted to the appellant throu gh the secure Internet portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure Internet portal/application.  See 310.10 for additional requirements related to notices sent via secure portal/applications.   B.  Development of the Appeal Case File  The reviewer must obtain and review all available and relevant information needed to make the determination.  All information considered by the appeals adjudicator in conducting the redetermination must be included in the case file.  Other areas within the  contractor may have information relevant to the claim(s) at issue.  For example, the medical review area may submit evidence to the reviewer for inclusion in the case file (e.g., documentation and correspondence related to provider education on the issues  appealed, any notices of review, and specific documentation requests to the provider and third parties).    In addition, contractors such as Recovery Audit Contractors (RACs), UPICs, or the Supplemental Medical Review Contractor (SMRC) may have other information from their review of claims that they wish to include in the case file.  Documentation submitted by a  provider, supplier or beneficiary (or other party to the appeal) as part of a prepayment (e.g. medical review or demand bill review) or postpayment (e.g. UPIC reviews) review, including clinical documentation, must be included in the appeals case file for  consideration during the redetermination.  If this documentation is not included in the appeals case file, the reviewer shall request the documentation from the claims review contractors (i.e., RACs, UPICs, and SMRCs) prior to rendering the redetermination decision.  The timeframes associated with request and delivery of medical records from the CMS claims review contractor to the MAC should be agreed upon in the Joint Operating Agreement (JOA).  The MACs should notify the respective Contracting Officers Representative if there is any difficulty obtaining documentation from the CMS contractors within the agreed upon timeframes established by the JOA.   If the claims review contractor confirms that it did not receive medical records from the provider, supplier, or beneficiary (or other party to the appeal) or the information is otherwise unavailable, and the documentation is needed to support a favorable resolution of the appeals case, then the MAC shall reach out to the provider, supplier, beneficiary (or other proper party to the appeal) to obtain the medical records, and any other supporting documentation, prior to rendering the redetermination decision.  The case file and redetermination decision letter shall document all attempts to obtain the medical records and/or any other support documentation prior to rendering the redetermination decision.    The development of the case file is important not only for the redetermination, but also to prepare for a potential appeal to the QIC.  Proper development of the case file will assist the contractor in timely transmitting the case file to the QIC upon request.  In instances of large overpayment cases involving many claims, this case file development is extremely important.   For example, with respect to overpayments that are determined through statistical sampling and extrapolation, appellants often challenge the sampling methodology and the extrapolation during the reconsideration or an ALJ hearing.  To avoid any documentation issues during subsequent appeals, contractors shall include all information detailed in IOM 100 -08, Chapter 8, 8.4.4 related to the sampling methodology and extrapolation in the case file.   When a reconsideration request is filed with the QIC, and the QIC requests a case file for a large overpayment case, it is critical the QIC obtain the case file timely so it can begin adjudication.  Therefore, it should be a priority for the contractor to adequately develop case files.   Evidence in the case file must be made available for inspection by an appellant or party upon request.  Reviewers must exercise care in determining the weight to give allegations of fraud and abuse where the source of the specified information is not provi ded.  Although the name of the beneficiary or other source that provided the information that triggered an investigation is not always provided or necessary when reviewing the evidence, the case file must include information on the independent, subsequentl y developed investigation that supports the claim decision (See subsection D, below, for instructions on development of documentation.)   C.  Conducting the Redetermination      1. Overview    The redetermination is an independent review of an initial determination. The individual performing the redetermination must not be the same person who made the initial determination.   The contractor reviews the evidence and findings upon which the initial determination was based, and any additional evidence the parties submit or the contractor obtains on its own.   For redeterminations of claims denied following a complex prepayment review, a complex post -payment review, or an automated post -payment review by a contractor, MACs shall limit their review to the reason(s) the claim or line item at issue was initially denied.  Prepayment reviews occur prior to Medicare payment, when a contractor conducts a review of the claim and/or supporting documentation to make an initial determination.  Post -payment review or audit refers to claims that were initially paid by Medic are and subsequently reopened and reviewed by, for example, a UPIC, RAC, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage, change coding, or reduce payment.  Complex reviews require a manual review of the supporting medical records to determine whether there is an improper payment.     Automated reviews use claims data analysis to identify improper payments.  If an appeal involves a claim or line item denied on an automated pre -payment basis, MACs may continue to develop new issues and evidence at their discretion and may issue unfavorable decisions for reasons other than those specified in the initial determination.    Contractors will continue to follow existing procedures regarding claim adjustments resulting from favorable appeal decisions.  These adjustments will process through CMS systems and may suspend due to system edits.  Claim adjustments that do not process t o payment because of additional system imposed payment limitations, conditions or restrictions (for example, frequency limits or National Correct Coding Initiative edits) may result in new denials with full appeal rights (i.e., the new denial will be consi dered an initial determination with respect to the appeals process).    If a MAC conducts an appeal of a claim or line item that was denied on pre - or post -payment review because a provider, supplier, or beneficiary failed to submit requested documentation, the MAC will review all applicable coverage and payment requirements f or the item or service at issue, including whether the item or service was medically reasonable and necessary.  As a result, claims initially denied for insufficient documentation may be denied on appeal if additional documentation is submitted and it does  not support medical necessity.    There may be times where the appellant requests a redetermination of an entire claim and there may be times where he/she requests a redetermination of a specific line item on the claim.  The contractor should review all aspects of the claim or line item necessary to respond to the appellants issue.  For example, if the appellant questions the amount paid, the contractor must also review medical necessity, coverage, deductible, and limitation on liability, if applicable.   If the appellant requests a redetermination of a specific line item, the contractor reviews all aspects of the claim related to that line item.  If appropriate, it reviews the entire claim.  If it reviews more than what the appellant indicated, it includ es an explanation in the rationale portion of the redetermination letter of why the other service(s)/item(s) were reviewed.   2. [Reserved]   3. Appeal Requests Filed on Resubmitted Claims   For appeals of a specific line item or service, the date of the first MSN or RA that states the coverage and payment decision is the date of the initial determination.  Adjustments to the initial claim or claim resubmissions for the same item/service on th e same date of service that are included on subsequent MSNs or RAs,  but do not revise the initial determination, do not extend/change the appeal rights on the initial determination.   4. Fraud   Although the reviewer may not make a finding of criminal or civil fraud (see 280, Fraud and Abuse), the reviewer should review the claim to see if there is sufficient documentation and evidence supporting that the items or services were actually furnish ed or were furnished as billed.  5. Appeals Involving Overpayments   For appeals that involve overpayments, the contractor shall review all aspects of the overpayment, including the validity of the overpayment, whether the amount of the overpayment was correctly calculated and extrapolated (if applicable), who is responsibl e for the overpayment, and whether recovery of the overpayment should be waived under 1870 of the Act.  For additional information see IOM 100- 06 Chapter 3, sections 70 through 110.  If the redetermination involves an extrapolated overpayment and the appellant challenges the validity of the sampling methodology, the contractor reviews the claims in question as well as the methodology used to extrapolate the overpayment amount.  For bac kground on how the UPICs use statistical sampling to estimate overpayments, see IOM 100- 08, Chapter 8, section 8.4.  If a reconsideration is subsequently requested, the entire case will be sent.   6.  Evidence   Appellants have the opportunity to submit written evidence and arguments relating to the claim at issue.  Contractors must accept and consider any relevant documentation submitted. Contractors may also accept this information via facsimile and/or a secure Internet portal/application.   D.  Requests for Documentation   1.  Requesting Documentation for State -Initiated Appeals   The reviewer should not request documentation directly from a provider or supplier for a State - initiated appeal.  If additional documentation is needed, the reviewer should request that the submitter of the appeal (i.e., the State or the party authorized to act on behalf of the Medicaid State Agency) obtain and submit necessary documentation.  The requested documents may be submitted via facsimile or via a secure Internet portal/application.  Documentation previously submitted by the State or the provider/supplier as part of a demand bill review must be included in the appeals case file for review during the redetermination (see 310.4.B).  2.  Requesting Documentation for Provider or Supplier- Initiated Appeals   For provider and supplier initiated appeals, when necessary documentation has not been submitted, the reviewer advises the provider or supplier to submit the required documentation. The reviewer notifies the provider or supplier of the timeframe the provider or supplier has to submit the documentation.  The reviewer documents the request in the redetermination case file.  The requested documents may be submitted via facsimile and/or via a secure Internet portal/application. In some situations, a provider or  supplier may inform the reviewer that it is having trouble obtaining supporting documentation from another provider or supplier (e.g., an ambulance supplier who is requested to submit hospital admission records).  In this situation, the contractor may ass ist the provider or supplier in obtaining records. If the additional documentation that was requested is not received within 14 calendar days from the date of request, the reviewer conducts the redetermination based on the information in the file.  The reviewer must consider evidence that is received after the 14 -day deadline but before having made and issued the redetermination.  See 310.4.D.4 below for information on the extension of the decision making timeframe for additional documentation that is subm itted after the request.   3.  Requesting Documentation for Beneficiary -Initiated Appeals   For beneficiary initiated appeals, when necessary documentation has not been submitted, the reviewer advises the provider or supplier to submit the required documentation.  The reviewer documents the request in the redetermination case file.  The reviewer notifies the beneficiary (either in writing or via a telephone call) when the reviewer has asked the beneficiarys provider or supplier for additional documentation.  The reviewer also notifies the beneficiary that the provider or supplier has 14 calendar days to submit the additional documentation that has been requested, and that if the documentation is not submitted, the reviewer will decide based on the evidence in the case file.  If the reviewer sends the beneficiary a letter, it must include a descrip tion of the documentation that has been requested. The reviewer shall document all notifications and correspondence to and from the beneficiary in the redetermination case file.   4.  Extension for Receipt of Additional Documentation   Contractors shall educate parties to include all supporting documentation with the redetermination requests submitted via mail, facsimile or a secure Internet portal/application. However, when a party submits additional evidence (via mail, facsimile or a s ecure Internet portal/application) after filing the request for redetermination, the contractors 60 -day decision-  making timeframe is automatically extended for up to 14 calendar days for each submission.