(Medicare Claims Processing Manual)

The person submitting the request does not a utom atically become  the representative until a nd unl ess an appointm ent of representative form or othe r written statement is c ompl eted (see 270 f or instructions on developing an inc ompl ete or absent appointm ent of representative).  There will be  circumst ances wh ere the mental and/or physical incapacity of the beneficiary becom es an issue. Based on all the  documented medical in formation a vailable, the contractor m ay decide  to allow the  person submitting  the request for redetermination t o act on be half of a beneficiary who is m entally or physically incapacitated. The  contractors decision, a s well as the b eneficiarys incapacita tion, should be  documented in the  file and suppor ted by relevant medical doc umentation.  1.  R equests for Redetermination Subm itted by Members of  Congress  When the  contractor  has honore d a request for redetermination f iled by a Member of Congress pu rsuant to a  Congre ssional inqui ry made on be half of a beneficiary or provider , physician or othe r suppli er, the contractor may continue  to provide the Member of Congress with st atus in formation on the  appeal a t issu e.  Status in formation inc ludes the progression of  the appeal th rough the  administra tive appeals process, including information on whe ther or when an appeal d etermination or  decision ha s been issu ed and wha t the decision w as (e.g., favorable, unfa vorable, partially favorable), but doe s not inc lude release of personal information a bout a be neficiary that the Member of Congress did not a lready have in his/h er possession. A beneficiary may want a Member of Congress to obt ain mo re detailed information a bout his/he r appeal without a ppointing the Member of Congress as a representative.  In this cas e, it would be necessa ry for the beneficiary to sign a release of information. The  contractor must accept  any of the  following as releases of information:   A signed copy of corresponde nce from the  beneficiary expressing a  desire for the c ongre ssion al office to obtain information on his/he r behalf;   A release of information form developed by the congression al office; or   A release of information form developed by the contractor  for this pu rpose.  If the Member of Congress expresses an interest i n acting a s the representative of a beneficiary or of a provider, physician, or other suppli er, the party must c ompl ete an appointm ent of re presentative form or written statement.  B. Wh at Constitutes a R equest for Redetermination  1. Wr itten Requests for Redetermination Made by Beneficiaries  Beneficiaries may request a redetermination by s ubmitting a c opy of th eir MSN, by filing a compl eted Form CMS-20027 or by submitting a l etter that indi cates dissatisfa ction w ith a c laim d etermination.  As not ed above , appeal r equests re ceived via  a facsimile  or secure Internet portal/application sha ll also be  consid ered recei ved in w riting.  Requests for redetermination m ay be submitte d in situ ations w here beneficiaries assume  that they will r eceive a re determination b y questioning  a payment de tail of the determination or  by sending additiona l information bac k with t he MSN, but don t actu ally say: I want a review.  For example, a written inqui ry stating, Why did you onl y pay $10.00?  is considered a  request for redetermination. C ommon examples of phrasing in letters from be neficiaries that constitute  requests for redetermination in clude, but ar e not limite d to the  follo wing:   Please reconside r my claim.   I am not s atisfied with t he amount pa id - please look a t it again.   My neighbor  got pa id for the same kind of  claim. My claim should be  paid too.   The request may contain the  word appeal or review.  Th ere may be instances in whi ch the  word review is used but w here the clear intent of the request is f or a status re port.  This should be c onsidered an inqui ry.  2.  Wr itten Requests for Redetermination Sub mitted by a S tate, Provider, Physician or O ther Supplie r  States, provider s, ph ysicians, or  othe r suppli ers with appeal r ights must submit w ritten requests via  mail, facsimile  or secure Internet portal/application ( if the  contractor choos es to r eceive requests via fac simile  or CMS approve d secure Internet portal/applic ation)  indicating  what they are appealin g and w hy. A redetermination r equest may be submitte d using:   a.   A  completed Form CMS-20027 c onstitu tes a request for re determination.  Compl eted means that all applic able spa ces are fille d out and all necessary  attachments are in cluded with the  request. The form c an be found o n the  CMS website at: http://www.c ms.gov/ cmsforms/do wnloads/ cms20027.pdf   b.   A  written request/letter.  At a minimum, the  request must c ontain the  following information:   1.  B eneficiary name; 2.  M edicare numbe r; 3.  The  specific service(s) and/or  item(s) for which the  redetermination is b eing re quested; 4.  The  specific date(s) of the service; and 5. The name of the party or the representative of the party.  Frequently, a party will w rite to a contractor  concerning the initia l determination inst ead of  filing F orm CMS-20027. How  to ha ndle such letters depends upon the ir content and/or  wording.  A letter serves as a request for redetermination if  it contains the  information liste d above  and either: (1) explicitly asks the  contractor  to take further action, or  (2) indicates dissatisfaction with the c ontracto rs decision. T he contractor counts the  receipt a nd pr ocessing  of the letter as an appeal only if it treats it a s a request for redetermination.   NOTE :  The details of  its actions must be detailed (e .g., whe n action w as taken and wh at was don e) for possible  subs equent evidentiary and administra tive purposes.  c.   A secure Internet portal /appli cation. If a contractor has received CMS approval for the  use of a secure Internet portal/application to suppor t appeals a ctivitie s, appellants m ay (but are  not r equired to) submit re determination re quests via  the secure Internet portal/application. W ritten requests submit ted via  the portal/application sha ll include the required elements for a valid appeal r equest as outlined above  unde r 310.1.B.2.b.  NOTE: Some redetermination re quests m ay contain attachm ents.  F or example, if the RA is a ttache d to the  redetermination re quest that doe s not contain the  dates of service on the  cover and the  dates of service are highlighted or emphasized in some  manner on the  attached RA, this is a n acceptable redetermination request.  Where the required information is not listed on the request form but is provided within the documents or attachments submitted with the appeal, the request substantially complies with the requirements established in 42 CFR 405.944.  MACs shall not dismiss requests under 42 CFR 405.952(b)(2)  when redeterminations substantially comply with requirements.    3.  How  to Han dle Incomplete Requests for Redetermination:  If any of the above  information refe renced in S ection 2 is not inc luded with an a ppeal r equest submitte d by a party  or th eir representative  (other than a b eneficiary, or a be neficiarys representative ), the request is conside red inc ompl ete and the  contractor  issues a dismissal notic e with a n explanation of  the information that must be  included (see 310.6 f or more information on dismiss als).  Contra ctors should not c onside r beneficiary requests as in compl ete, whether filed by the  beneficiary or by their representative .  Contra ctors must c ontact beneficiaries (or their representative s), when necessary, to obtain missing information neede d to process the r edetermination.   4.  How  to Han dle Multiple Requests for Redetermination for the Same Item/Service:  a. Duplicate requests (multiple  requests from same part y) while an appeal is p ending.  If an app eal for an it em or s ervice is pending and the  appellant submits a duplic ate request for re determination, the  contractor combine s the requests into one  redetermin ation.  T he contra ctor shall in clude verbiage  indicating that dupli cate requests for re determination had been r eceived (on w hat dat es and via what venues, if multiple  venues were utiliz ed).  Adjudi cation time  fram es are still bas ed on the  first request for re determin ation.  N OTE: See 310.4.D.4 for ex tending adjudi cation time fram es if additional information  is submitte d with the  second appe al request.   If the contra ctor id entifie s a patt ern in w hich an app ellant or groups of app ellants are  repeatedly submitting dupli cate requests for re determination, the  contra ctor shall ta ke additional st eps to e ducate the appellant r egarding the  appeals pro cess.  b. M ultiple  requests from different parti es while an appeal is p ending.  If an app eal for an it em or service is pending and anothe r party  to the  redetermination submits a r equest for re determination, the  contractor shall c ombine  the redetermination r equests and issue  a decision w ithin 60 da ys of the  latest filed request, in a ccordan ce with 42 C FR 405.944( c).   When issuing the  decisi on or dismissal noti ce, the  contra ctor shall in clude verbiage  indicating that requests for re determination had been r eceived from multiple  parti es (on w hat dat es and via w hat venues, if multiple  venues were utiliz ed) so that it is c lear to the  parti es that the  decision or dismissal was issu ed timely in accordan ce with 42 C FR 405.950( b)(2).  c. Duplicate or m ultiple  requests wh en an appeal is complete.  If a decision or dismissal notic e has been issu ed (including an M SN or RA for a fu lly favorable  decisio n), and the  contra ctor recei ves an additional r equest for re determination for that ite m/service (a duplicate request from the  appellant or a subsequent request from a diffe rent part y), the contra ctor shall tr eat the additional r equest as an inquir y.  The contra ctor dir ects the  party  to file  a request for reconside ration w ith the  appropriate  QIC.  d. Workload - Whenever the contra ctor combine s duplicate or multiple  requests for re determination as explained above , the contra ctor shall e nsure  that the  workload r eporting r eflects one  redetermination receipt and one  redetermination c ompl eted.  NOT E:  If a party  files a request for reco nsideration  with the  contra ctor after a redetermination d ecision or dismissal no tice has b een issu ed, the  contra ctor tr eats the  reconside ration r equest as misfile d and f orwards the request to the  QIC for a r econside ration in a ccordan ce with 320.1.B.   Contracto rs shall not issue a dismiss al noti ce in response  to a dupli cate request or multiple r equests for redetermina tion.  NOTE: In accordance with IOM 100- 04, c hapter 29, s ection 310.6.3, if  an appellant requests th at the contractor vacate its dismiss al action, or  an app ellant ref iles a corrected appeal in re spons e to a dismiss al, and the  contractor  determines that it cannot vacat e the dismiss al, then it s ends a l etter notifying the appellant accordingly.  If evidence or information not previously submitted with the redetermination request is submitted with the request to vacate the dismissal, the letter must specifically address that new evidence or information.  T he contractor shall not issue  a second dismiss al noti ce to the  appellant.