(Medicare Claims Processing Manual)

2. If you think we have incorrectly dismissed your request (that is, you believe you did address all of the above listed items in your request), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC).  Your request must be received by the QIC at the address below within 60 days of receipt of this letter.  In your request, please explain why you believe the dismissal was incorrect.  The QIC will not consider any evidence for establishing coverage of the claim(s) being  appealed.  Their examination will be limited to whether or not the dismissal was appropriate.  Please send your request to:   <INSERT QIC ADDRESS>   Sincerely.    NAME, TITLE  MAC NAME        (End) EXHIBIT 2           (Start) EXHIBIT 3:       MONTH, DATE, YEAR   APPELLANT NAME                                                   MEDICARE NUMBER OF  ADDRESS        BENEFICIARY:  CITY, STATE ZIP   CONTACT INFORMATION:  If you have questions, write or  call:  MAC Name  Address  City, State Zip  Telephone number   RE:  <Include claim identifier or appeal number>   Dear <Appellants Name>:   This letter is in response to your appeal request (also known as a redetermination) that was received in our office on <INSERT DATE>.  The redetermination was requested for dates of service <INSERT DATE(S)>.  The initial determination for the items/service s in dispute was issued on <INSERT DATE OF RA/MSN>.   Your redetermination request has been dismissed because the date(s) of service in question is/are past the time limit to file a request for a redetermination.  A redetermination request must be received in our office within 120 days of the date of receipt of the initial determination date  on the Medicare Remittance Advice or the Medicare Summary Notice.  The date of receipt of the initial determination is presumed to be 5 days after the date of the notice unless there is evidence to the contrary.  Model Redetermination Dismissal Notice For An Untimely Appeal    When we receive a request that has been filed late, we consider whether the appellant had good cause for filing late.  In special circumstances, we may allow additional time to file.  In this case, we did not find good cause for filing your request late.   If you disagree with this dismissal, you have two options:   1. You may request that we vacate our dismissal.  We will vacate our dismissal if you demonstrate good and sufficient cause for filing late.  Your request to vacate this dismissal must be received at the address above within 6 months of the date of receipt of  this notice.   2.  If you think we have incorrectly dismissed your request (for example, you believe you did file your request on time), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC).  Your request must be received by the QI C at the address below within 60 days of receipt of this letter.  In your request, please explain why you believe the dismissal was incorrect.  Please note that the QIC will not consider any evidence for establishing coverage of the claim(s) being appealed .  Their examination will be limited to whether or not the dismissal was appropriate.  Please send your request to:    <INSERT QIC ADDRESS>    Sincerely.     NAME, TITLE   MAC NAME       (End) Exhibit 3   310.6.3  Processing Requests to Vacate Dismissals (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  If a party submits a request to vacate the dismissal, and the request contains sufficient evidence or other documentation that supports a finding of good cause for late filing, the MAC makes a favorable good cause determination.  Where a finding for good cause is made, the MAC shall document the reason for that finding in the appeal decision letter, the appeal c ase file, or both.  Once it makes a favorable good cause determination, it considers the appeal to be timely filed, vacates its prior dismissal action, and performs a redetermination.  For the purposes of counting workload in CROWD and in the MAS, a determ ination to vacate a dismissal should be counted as a redetermination and not a reopening.   If the MAC does not find good cause to vacate the dismissal, the dismissal remains in effect.  The MAC issues a letter (not a dismissal letter) explaining that good cause has not been established and the dismissal cannot be vacated.  Although the appellant  may not appeal a MACs finding that good cause was not established when the appellant requested that the MAC vacate its dismissal, the appellant maintains their right to request a QIC review of the MACs dismissal action.  However, requests for QIC review  of a MACs dismissal action must be received by the QIC within 60 days of the date of receipt of the dismissal notice.  For purposes of counting workload in CROWD and in the MAS, a MACs determination not to vacate a dismissal action is counted as an inquiry, not as a dismissal action.   If an appellant requests that the MAC vacate the dismissal action, and the MAC determines that that it cannot vacate the dismissal, the MAC sends a letter notifying the appellant.  The MAC shall not issue a second dismissal notice to the appellant since a dismissal should only be issued in response to an appeal request.  A request to vacate a dismissal is not a request for an appeal.   If the contractor determines that the request to vacate the dismissal of the redetermination request does not provide good and sufficient cause to vacate, the contractor shall respond with a letter that addresses why the request to vacate does not meet the criteria for good cause.  Any evidence or information not previously submitted with the redetermination request that is submitted with the request to vacate the dismissal shall be addressed by the contractor in their letter.  The contractor must explain i n clear language why all evidence and information submitted, including what was sent with the request to vacate the dismissal, does not meet the requirement necessary to vacate the dismissal.   310.7 - Medicare Redetermination Notice (For Partly or Fully Unfavorable Redeterminations)    (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  The contractor uses the following Medicare Redetermination Noti ce (MRN) format or som ething simila r and st andard language paragraphs whe ther the redetermination noti ce is delivered via har d copy mail or via a CMS-approved por tal/application.     NOTE: This is a  mode l letter and should be  adjusted on a  case by case basis if necessa ry. Contracto rs may also in clude additiona l resources, including their website a ddress(es) and/or telephone  numbe r(s). Appeals th at involve  issues such as Me dicare Secondary Payer (MSP) and overpayment recov eries may require contractors to de viate from the  sample  given in this m anual section.  Contractors must also include reference within all appropriate sections of the appeal decision letter that in instances where services are covered (for example, a partially favorable decision is rendered), the beneficiary may also be responsible for any copayments, coinsurance, or deductibles related to the covered portion of the service or item that is payable.  The contractor must e nsure that the information i dentified in each s ection of the mode l letter below is included and addressed, as needed, in the  MRN.  C ontracto rs shall include the request for reconsideration f orm with the  MRN.  The  contractor  must f ill in the  contract numbe r and appe al number  on each request for reconsi deration form.  The  contract n umber is onl y required for contractors who h ave multiple  locations in whi ch a QIC will n eed to r equest a case file.  The appe al number  is any numbe r used to ide ntify the associated appeal and will be  used by the Q IC to request a case  file.  The  contractor also sh all include the contractor  logo or CMS logo with the  contractor  name and address on t he reconsideration re quest form for identification pur poses.  This log o will be used by the QIC to id entify which contractor to re quest the  case file from.  A. Redeterm ination Letter   The redetermination l etterhead must f ollow the  instructions issu ed by CMS for contractor written correspond ence requirements (see 290 ), unless oth erwise instructed and/or  agreed to b y CMS.   (Start) EXHIBIT 4:      MONTH, DATE, YEAR   APPELLANT NAME                                                   MEDICARE NUMBER OF  ADDRESS        BENEFICIARY:  CITY, STATE ZIP           CONTACT INFORMATION:          If you have questions, write or          call:          Contractor Name          Address          City, State Zip          Telephone number   RE:   <Include claim identifier or appeal number>   MEDICARE APPEAL DECISION  <If the appellant is a provider or supplier, in the beneficiarys letter, contractors must include language to indicate the beneficiary is receiving a copy of the decision. For example, This is a copy of the letter sent to <your provider> <your physician> <your supplier> <the party who requested this appeal> or, Please note that if you did not request this appea l, you are receiving this letter as a copy.>   Dear <Appellant's Name>:   Model Redetermination Notice     This letter is to inform you of the decision on your Medicare appeal. An appeal is a new and independent review of a claim. You are receiving this letter because you requested an appeal for <insert: description of item or service>.  The appeal decision is <Insert either: unfavorable. Medicare does not cover the item/service at issue in your appeal OR partially favorable. Medicare covers part of the claim(s) at issue in your appeal.>   <Note: If the issue in the appeal is strictly a payment dispute, the language should read, for unfavorable decisions: Medicare cannot make payment for the item/service at issue in your appeal and for partially favorable decisions: Medicare can make part ial payment for the item/service at issue in your appeal.>   More information on the decision is provided below. If you disagree with the decision, you may appeal to a Qualified Independent Contractor (QIC). Your appeal of this decision must be made in writing and received by the QIC within 180 days of receipt of this letter. You are presumed to have received this decision five days from the date of the letter unless there is evidence to show otherwise. However, if you do not wish to appeal this decision, you are not required to take any action. For more information on how to appeal this decision, see the section at the end of this letter entitled, Important Information about Your Appeal Rights.   A copy of this letter was also sent to <Insert: Beneficiary Name or Provider Name>.   <Insert: Contractor Name> was contracted by Medicare to review your appeal.   SUMMARY OF THE FACTS  <Instructions: Contractors may present this information in this format, or in paragraph form.>   Provider  Dates of Service  Type of Service  <Insert: Provider Name>  <Insert: Dates of Service>  <Insert: Type of Service>   A claim was submitted for <insert: kind of services and specific number>.   An initial determination on this claim was made on <insert: date>.   The <insert: service(s)/item(s)> were/was denied because <insert: reason>.   On <insert: date> we received a request for a redetermination.   <Insert: list of documents> was submitted with the request.        DECISION  <Instructions: Insert a brief statement of the decision, for example "We have determined that (the specific items/services) are not covered by Medicare. We have also determined that (the provider) (the supplier) (the beneficiary) is responsible for the cost of the item(s)/service(s).">   EXPLANATION OF THE DECISION     <Instructions: This is the most important element of the redetermination. Explain the logic/reasons that led to your final determination. Explain the coverage policy (LCD, NCD), regulations, policy guidance (IOM provisions), and/or laws used to make this determination. Make sure the rationale for the decision is clear and that it includes an explanation of why the claim can or cannot be paid for the particular set of facts at issue in the appeal. For example, the explanation should demonstrate how the benef iciarys condition or circumstances do not meet specific coverage policy requirements. Statements such as "not medically reasonable and necessary under Medicare guidelines" or "Medicare does not pay for X" provide conclusions instead of explanation, and ar e not sufficient to meet the requirement of this paragraph.>   WHO IS RESPONSIBLE FOR THE BILL?