(Medicare Claims Processing Manual Crosswalk)

60.1 12000.1 Initial Determination29 60.2  12000.2       PM-AB-00-122 Steps in the Appeals Process: Overview 29 60.3 12001 FI and Carrier Correspondence With Beneficiaries Or Other Parties Regarding Appeals 29 60.4  12002        Parties To An Appeal 29 60.5  12004        Appointment Of Representative 29 60.5.1  12004.1 600 287.4B 257B 383B  628  Appointment of Representative - Introduction 29 60.5.2  12004.2        Who May Be A Representative 29 60.5.3  12004.3        How to Make and Revoke an Appointment 29 60.5.4  12004.4        When to Submit the Appointment 29 60.5.5  12004.5        Where to Submit the Appointment 29 60.5.6 12004.6 PM-B-02-074 Right s and Responsibilities of a Representative 29 60.5.7  12004.7        Validity of an Appointment Over Time 29 60.5.8 12004.8 Timeliness of an Appeal Request and Completeness of Appointment 29 60.5.9  12004.9        Powers of Attorney 29 60.5.10  12004.1        Incapacitation or Death of Beneficiary 29 60.5.11 12004.11 Disclosure of Individually Identifiable Beneficiary Information to Representative Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.6  12006        Amount In Controversy 29 60.6.1  12006.1        Amount in Controversy Defined 29 60.6.2  12006.2        Amount in Controversy General Requirements 29 60.6.3  12006.3        Calculating the Amount in Controversy 29                                                                                                    60.6.4 12006.4 Additional Considerations for Calculation of the Amount in Controversy 29 60.6.5 12006.5 Aggregation of Claims to Meet the Amount in Controversy 29 60.7 12008 Extension Of Time Limit For Filing A Request For Review Or Fair Hearing 29 60.7.1 12008.1 Good Cause29 60.7.2  12008.2        General Procedure to Establish Good Cause 29 60.7.3 12008.3 Conditions that May Establish Good Cause for Late Filing by Beneficiaries 29 60.7.4 12008.4 Examples of Situations Where Good Cause for Late Filing Exists for Beneficiaries 29 60.7.5 12008.5 Conditions that May Establish Good Cause for Late Filing by Physicians or Other Suppliers 29 60.7.6 12008.6 Examples of Situations Where Good Cause for Late Filing Exists for Physician or Other Suppliers 29 60.7.7 12008.7 Good Cause Not Found for Beneficiary, or for Provider, Physician or Other Supplier 29 60.8  12009        Fraud And Abuse 29 60.8.1  12009.1        Fraud and Abuse - Authority Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29                                                                                                                 60.8.2 12009.2 Inclusion and Consideration of Evidence of Fraud and/or Abuse 29 60.8.3 12009.3 QIO-7560 Claims Where There Is Evidence That Items or Services Were Not Furnished, or Were Not Furnished as Billed 29 60.8.4 12009.4  Responsibilities of Reviewers and Hearing Officers 29 60.8.5  12009.5        Requests to Suspend the Appeals Process 29 60.8.6 12009.6 Continuing Appeals of Providers, Physicians or Other Suppliers Who are Under Fraud or Abuse Investigations 29 60.8.7 12009.7 Appeals of Claims Involving Excluded Providers, Physicians or Other Suppliers 29 60.9  12010        Guidelines For Writing Appeals Correspondence 29 60.9.1 12010.1 General Guidelines29 60.9.2 12010.2 Letter Format29 60.9.3  12010.3        Required Elements in Appeals Correspondence 29 60.10  12011        Disclosure Of Information 29 60.10.1 12011.1 General Information29 60.10.2  12011.2        Fraud and Abuse Investigations 29 60.10.3  12011.3        Medical Consultants Used 29 60.10.4 12011.4 Multiple Beneficiaries29 60.11  12012        Review - The First Level Of Appeal  29 60.11.1  12012.1        Filing a Request for Review 29 60.11.2 12012.2 Time Li mit for Filing a Request for Review Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29                                                         60.11.3 12012.3 Recording of Inquiries and Other Actions on the Carrier Appeal Report (FI - Form CMS-2591, Carrier - Form CMS-2590) 29 60.11.4 12012.4 The Review29 60.11.5  12012.5        The Review Determination 29 60.11.6  12012.6        Review Determination Letter 29 60.11.7  12012.7        Effect of the Review Determination 29 60.12  12013        Telephone Review Procedures 29 60.12.1 3795 12013.1 RO-9005.3 Informing the Beneficiary and Provider Communities about The Telephone Review Process 29 60.12.2 3796 12013.2        Issues for Telephone Reviews 29 60.12.3 3796.1 12013.3        Issues During the Telephone Review 29 60.12.4 3797 12013.4        Time Limit for Requesting a Telephone Review 29 60.12.5 12013.5 Review Requests Made on Behalf of the Party on the Telephone 29 60.12.6 3790 12013.6       QIO-7400 Conducting the Telephone Review 29 60.12.7 3790.1 12013.7        Documenting the Call 29 60.12.8 3790.2 12013.8        Timely Processing Requirements 29 60.12.9 3799 12013.9 620 288  384  630  Review Determination Letters 29 60.12.10 12013.10 Education29 60.12.11  12013.11        Monitoring Telephone Reviews 29 60.13  12014        Fair Hearing - The Second Level Of Appeal 29 60.13.1  12014.1        Filing a Request for Fair hearing Chap.                                                                                                          Qualif ications and General Responsibilities Sect Int. Pub.13-3  Carrier Pub.14-3  OPT Pub. 09 HO Pub. 10 HH Pub. 11  SNF Pub. 12 Disqualification of HO HSP Pub. 21 RHC Pub. 27 OTHER Description29 60.13.2 12014.2 Time Limit for Filing A Request for Fair Hearing 29 60.13.3 12014.3 Request for HO hearing Filed Prior to a Review Determination 29 60.13.4 12014.4 Exceptions to Filing Requirements 29 60.14  12016        Request For HO Hearing 29 60.14.1  12016.1        Timely Processing Requirements 29 60.14.2 12016.2 Cont ractor Responsibilities  General 29 60.14.3  12016.3        Requests for Transfer of In-Person Hearings 29 60.14.4  12016.4        Acknowledgment of Request for HO hearing 29 60.14.5  12016.5        Case File Development 29 60.14.6  12016.6        Case File Preparation 29 60.15  12017        Types Of Fair Hearings 29 60.15.1 12017.1 In-Person Hearing29 60.15.2 12017.2 Telephone Hearing29 60.15.3  12017.3        On-the-Record (OTR) Hearing and Decision 29 60.15.4 12017.4 Preliminary On-The-Record (POTR) Hearing and Decision 29 60.16 12018 Hearing Officer (HO) Authority And Responsibilities 29 60.16.1  12018.1        Hearing Officer (HO) Authority 29 60.16.2 12018.229 60.16.3  12018.3 Chap.                                                                                    Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 29 OTHER60.17 Description 12019        Fair Hearing Procedures 29 60.17.1  12019.1        Preparation for the Fair Hearing 29 60.17.2 12019.2 Scheduling the Date, Time and Place of Hearing 29 60.17.3 12019.3 Adjournment and/or Postponement of Telephone or In-person Hearing 29 60.17.4  12019.4        Pre-Hearing Review of the Evidence 29 60.17.5 12019.5 Forwarding Copy of Case File Prior to Telephone Hearing 29 60.17.6  12019.6        In-Person and Telephone HO hearing Procedures 29 60.17.7  12019.7        The Fair Decision Timeliness 29 60.18  12020        Effectuation Of Fair Hearing Decisions 29 60.18.1 12020.1 General Rule29 60.18.2 12020.2 Delaying Effectuation29 60.18.3 12020.3 Elemen ts of Written Request for Reopening 29 60.18.4  12020.4        Notice to Parties of Reopening Request 29 60.18.5  12020.5        HO Reply to Reopening Request 29 60.18.6  12020.6        Notice to Parties of HO Determination 29 60.19 12026 Requests For Part B Administrative Law Judge (ALJ) Hearing 29 60.19.1  12026.1        Right to Part B ALJ Hearing 29 60.19.2  12026.2        Forwarding Requests to SSA/OHA 29 60.19.3  12026.3        Case File Preparation Chap.