(Medicare Claims Processing Manual Crosswalk)

Medicare Claims Processing Manual Chapter 29 - Appeals of Claim Decisions Crosswalk  Note: QIO appeals instructions are to remain in the QIO Manual.  Some background material  is repeated here to enhance understanding. 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 OTHER Description29 01 Foreword29 10 3790 12000 600 287 256 380 408 628 QIO-740 CMS Decisions Subject to the Administrative Appeals Process 29 20 3780 12000 600 287.4 256 383 408 628 QIO-740 Who may Appeal 29 30   600 287  383  628  Where to Appeal 29 30.1   600B       Social Security Office (SSO) 29 30.2          Part A Intermediary (FI) 29 30.2.1 FI Initial Determinations with Respect to Beneficiaries 29 30.2.2 Provider's Right to Appeal Certain Initial Determinations 29 30.2.3 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 30.3  12000        Part B Carrier 29 30.4 QIO-7400 Quality  Improvement Organization (QIO) 29 30.4.1         QIO-7400 QIO Reconsiderations and Appeals 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                                                                                                   30.5 HMO-2403 Health Maintenance Organizations (HMO) and Managed Care + Choice Organizations 29 30.6         RO-3600 CMS Regional Office Responsibility 29 30.6.1         RO-3600 Assisting FIs to Obtain Documentation 29 30.6.2         RO-3610 Congressional Requests for Part A Reconsideration 29 30.7         PM-AB-02-111 Time Limits for Filing Appeals 29 30.8         PM-AB-02-111 Amount In Controversy Requirements 29 40 3781   287.4 257 383A  628A PM-AB-00-122 Part A Appeals Procedures 29 40.1 3781 Initial Determinations29 40.1.1 3781.1 Initial Determin ations With Respect to Beneficiaries 29 40.1.2 3781.2 287.2  381 Provider's Right to Appeal Certain Initial Determinations 29 40.1.3 3781.3 287.3  382 Situati ons Where Provider May Initiate Appeal 29 40.1.4 3781.4 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 40.1.5 3781.6 Finding Good Cause for the Late Filing of Appeal Requests 29 40.1.5.1 3781.6A General29 40.1.5.2 3781.6B         Establishment of Time Limit for Filing 29 40.1.5.3 3781.6C Conditions Which Establish Good Cause 29 40.1.5.4 3781.6D         Procedure to Establish Good Cause 29 40.1.5.5 3781.6E         Examples of Situations Where Good Cause Exists 29 40.1.5.6 3781.6F         Where Good Cause Is Not Found 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 40.1.6 3781.7         Assisting Handicapped Beneficiaries 29 40.2 3782         Reconsideration of a Part A Payment Determination 29                                                                                                      40.2.1 3782.1 Place and Manner of Filing Requests for Reconsideration 29 40.2.2 3782.2 Completing Form CMS-2649, Request for Reconsideration of Part A Health Insurance Benefits 29 40.2.3 3782.3         Routing the Reconsideration Request 29 40.2.4 3782.4 Acknowledging Receipt29 40.2.5 3782.5 Transferring and Dismissing Requests Which Involve Partial or No Jurisdiction, More Than One Component, Stay, or Issue 29 40.2.6 3782.7 Handling of Request--Beneficiary Appeals Before Initial Determination Is Made or After Initial Favorable Determination Is Made, But Before They Are Notified 29 40.2.7 3782.8         Withdrawal of Request 29 40.2.8 3782.9 Notifying Provider or Beneficiary Where There Is a Withdrawal 29 40.3 3783         Documenting Part A Reconsideration Requests 29 40.3.1 3783.1 Documentation Sources29 40.3.2 3783.2         Assembling the File 29 40.3.3 3783.3 PM-AB-00-122 Development29 40.4 3784 Evaluating the Evidence and Making the Reconsideration Determination 29 40.4.1 3784.1         Evaluating the Evidence 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                                                                             40.4.2 3784.2 Review Prior to Reversal of Initial Payment Determination 29 40.4.3 3784.3        AB-90-12 Preparing the Determination 29 40.4.4 3784.4         Completing the Determination 29 40.4.5 3784.5         Notice of Further Appeal Rights 29 40.4.6 3784.6         Preventing Duplicate Payment in Reversal Cases 29 40.4.7 3784.7 Effect of a Reconsideration Determination and Effectuation 29 40.4.7.1 PM-A-00-32 Effectuating Favorable Final Appellate Decisions That a Beneficiary is Confined to Home  Regional Home Health Intermediaries (RHHIs) Only 29 40.4.8 3784.9         Reconsideration Guide Language 29 40.4.8.1 PM-A-01-21 Sample Paragraphs to Be Used by FIs in Sequence as Shown below 29 40.5 3785         Request for Hearing under Part A 29 40.5.1 3785.1         Determining The Amount In Controversy 29 40.5.2 3785.2         Request Filed With SSO 29 40.5.3 3785.3         Request For Hearing Filed With The FI 29 40.5.4 3785.4 Request For Hearings FI s Receive Pertaining To QIO or HMO 29 40.5.4.1 3785.4 Request For Hearings FI s Receive Pertaining To QIO 29 40.5.4.2 3785.4 Request For Hearings FI s Receive Pertaining To HMO 29 40.5.5 3785.5         Action On Incoming Requests 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 40.5.6 3785.6         Request For Claim File (Sent By Hearing Office) 29 40.5.7 3785.7         Examination Of Claim File 29 40.5.8 3785.8         Prehearing Case Review 29 40.5.9 3785.9         Routing The Hearing Claim File 29 40.5.10 3785.10         Standard Exhibits Referred To In 40.50-40.50.9 29                                                                                                    40.6 3786 Scope and Effect of OHA, SSA Administrative Law Judge (ALJ) Decisions under Part A 29 40.7 3787 Effectuation of Reversal of Decision Where There Was Subsequent Utilization of Benefits in the Same Benefit Period 29 40.8 3788         Effect of Court Decisions 29 40.9  12019        Right to Representation Under Part A 29 40.10 3790 Reconsiderations, Hearings, and Appeals Where a QIO Has Review Responsibility 29 40.10.1 3790.1 Reconsiderations29 40.10.2 3790.3 Hearings29 40.10.3 Appeals of Institutional Supplementary Medical Insurance (Part B) Claim Decisions 29 40.11 3798 287.5  Appeals by Hospitals of Diagnosis-related Group (DRG) Assignments under PPS 29 50           Part B Appeals Procedures - FIs 29 50.1 3791 FI - Review, And Fair Hearing - Supplemental Medical Insurance 29 50.2 3792 Extension Of  Time Limit For Filing An Appeal 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                                                         50.3 3793 Review29 50.3.1 3793.1 What Constitutes a Request for Review - Handling Beneficiary Inquiries 29 50.3.2 3793.2         Elements of a Review 29 50.3.3 3793.3 Actions Prior to Reversal of Initial Payment Decision 29 50.4 3794 The Hearing29 50.4.1 3794.1         Types of Hearings 29 50.4.2 3794.2         Issues Determined at the Hearing 29 50.4.3 3794.3         Request for Hearing 29 50.4.4 3794.4         Hearing Officer (HO) 29 50.4.5 3794.5         Preparation for the Hearing 29 50.4.6 3794.6         Conduct of an In-Person or Telephone Hearing 29 50.4.7 3794.7         Parties to the Hearing 29 50.4.8 3794.8         In-Person and Telephone Hearing Procedures 29 50.4.9 3794.9         On The Record Decision 29 50.4.10 3794.10  Hearing Decision29 50.4.11 3794.11         Content of Hearing Decision 29 50.4.12 3794.12         Style of Hearing Decision 29 50.4.13 3794.13         Effectuation of HO Decision 29 50.5 3795         RO Examination Of Hearing Decisions 29 50.6 3796         Fraud And Abuse 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 50.6.1 3796.1         Disclosure of Information 29 50.7 3797         Requests For Hearing Before An ALJ 29 60  12000    383B  628B  Part B Appeals Procedures 29