(Medicare Claims Processing Manual)

(16) Under the Medicare Secondary Payer provisions of section 1862(b)  of the Act that Medicare has a recovery claim if Medicare is pursuing recovery directly from an applicable plan. That is, there is an initial determination with respect to the amount and existence of the recovery claim.    C.  Actions That Are Not Initial Determinations    Actions that are not initial determinations and are not appealable under this chapter include, but are not limited to     (1) Any determination for which CMS has sole responsibility, for example: whether an entity meets the conditions for participation in the program; whether an independent laboratory meets the conditions  for coverage of services; or a determination under the Medicare Secondary Payer provisions of section 1862(b)  of the Act of the debtor for a particular recovery claim;     (2) The coinsurance amounts prescribed by regulation for outpatient services under the prospective payment system;    (3) Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a contractor has sole responsibility under Part B, such as the establishment of a fee schedule set forth in 42 CFR, part 414, subpart B , or an inherent reasonableness adjustment pursuant to 42 CFR  405.502(g)  and any issue regarding the cost report settlement process under Part A:    NOTE:  For example, section 1848(i)(1)  of the Act prohibits administrative and judicial review of the individual components used to compute Medicare physician fee schedule payment amounts.  However, a payment amount determination with respect to a particular item or service on a claim is an initial determination that is appealable.    (4) Whether an individual's appeal meets the qualifications for expedited access to judicial review provided in 42 CFR 405.990;     (5) Any determination regarding whether a Medicare overpayment claim should be compromised, or collection action terminated or suspended under the Federal Claims Collection Act of 1966, as amended;    (6) Determinations regarding the transfer or discharge of residents of skilled nursing facilities in accordance with 42 CFR 483.5 (definition of transfer and discharge) and 483.15;     (7) Determinations regarding the readmission screening and annual resident review processes required by 42 CFR part 483, subparts C and E ;    (8) Determinations with respect to a waiver of Medicare Secondary Payer recovery under section  1862(b)  of the Act;    (9) Determinations with respect to a waiver of interest;    (10) Determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions (as opposed to the application in a particular case);    (11) Determinations under the Medicare Secondary Payer provisions of section 1862(b)  of the Act that Medicare has a recovery against  an entity that was or is required or responsible (directly, as an insurer or self -insurer; as a third party administrator; as an employer that sponsors, contributes to or facilitates a group health plan or a large group health plan; or otherwise) to make p ayment for services or items that were already reimbursed by the Medicare program, except with respect to the amount and existence of a recovery claim under section 1862(b) of the Act where Medicare is pursuing recovery directly from an applicable plan as  specified in 42 CFR 405.924(b)(16) ;    (12) A contractor's, QIC's, ALJ's, OMHA attorney adjudicators, or Appeals Councils determination or decision to reopen or not to reopen an initial determination, redetermination, reconsideration, hearing decision, or review decision;    (13) Determinations that CMS or its contractors may participate in the proceedings on a request for an ALJ hearing or act as parties in an ALJ hearing or Appeals Council review;    (14) Determinations that a provider or supplier failed to submit a claim timely or failed to submit a timely claim despite being requested to do so by the beneficiary or the beneficiarys subrogee;    (15) Determinations with respect to whether an entity qualifies for an exception to the electronic claims submission requirement under  42 CFR part 424;     (16) Determinations by the Secretary of sustained or high levels of payment errors in accordance with section  1893(f)(3)(B);     (17) A contractor's prior determination related to coverage of physicians' services;    (18) Requests for anticipated payment under the home health prospective payment system under  42 CFR 409.43(c)(ii)(s) ; and    (19) Claim submissions on forms/formats that are incomplete, invalid, or do not meet the requirements of a Medicare claim and returned or rejected to the provider or supplier.    NOTE: Duplicate items and services are not afforded appeal rights, unless the supplier is appealing whether or not the service was, in fact, a duplicate.    D.  Initial Determinations Subject to Reopening    Minor errors or omissions in an initial determination may be corrected only through the contractors reopening process.  Since it is neither cost efficient or necessary for contractors to correct clerical errors through the appeals process, requests for adjustments to claims resulting from clerical errors must be handled and processed as reopenings.  In situations where a provider, supplier, or beneficiary requests an appeal and the issue involves a minor error or omission, irrespective of the request for a n appeal, contractors shall treat the request as a request for reopening.  A contractor must transfer the appeal request to the reopenings unit or other designated unit for processing. See Chapter 34 Section 10.1 Authority to Conduct a Reopening of the Medicare Claims Processing Manual for information specific to conducting a reopening when a redetermination was requested.   210 - Who May Appeal  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10 - 01-19)  A person or  entity with a  right to a ppeal an initia l determination is c onsidered a party to the re determination (as described in 42 C FR 405.906) , referred to in the  remainder of these inst ructions a s a "party."  Parties to the  initia l determination in clude:   Beneficiaries, who a re almost a lways considered parties to a  Medicare determination, as th ey are entitle d to a ppeal any initia l determination (unless the  beneficiary has assigned his or  her appeal rights);   Provider s who f ile a claim for items or  services furnishe d to a  beneficiary.  NOTE:  A non-participating provider, that is, an entity eligible to enter into a provider agreement to participate in Medicare but has not entered into such an agreement, is not considered a provider or provider of service and does not have party status for an i nitial determination or appeal.  Beneficiaries are parties to claims filed for services furnished by a non- participating provider;    Participating suppli ers and non- participating suppliers, but only with respect to items or services furnished to a beneficiary that are billed on an assignment -related basis;    An applicable plan (as defined in 110) with respect to the amount and existence of a recovery claim under 405.924(b)(16)  if Medicare is pursuing recovery directly from the applicable plan.  The applicable plan is the sole party to an initial determination under 405.924(b)(16)  and any subsequent appeal.  Parties to the  redetermination a nd subs equent appeal levels include:   The parties to the  initia l determination, a bove ;  NOTE:  In addition to his/he r own r ight to a ppeal  Medicares decision r egarding an initia l determination, a  beneficiary is a party to any request for redetermination f iled by a provide r or suppli er.  The  beneficiary is always a party to an appeal of  services rendered on the ir behalf, at any level (except w hen the  beneficiary has assigned his/he r appeal rights to a  provide r or suppli er).   A nonpar ticipating suppli er has the same rights to appeal the  contracto rs determination in a n unassigned claim for medical equipm ent and suppli es if the contractor denies payment on the  basis of 1862( a)(1), 1834(a )(17)(B), 18 34(j)(1), or 1834 (a)(15) of the Act as a nonpar ticipating or participating suppli er has in a ssigned claims.  Th ese rights of  appeal a lso extend to de terminations that a refund is re quired either because the supplier knew or should ha ve known tha t Medicare would not pa y for the item or service (See 1834 (j)(4)), or becaus e the beneficiary was not pr operly informed in w riting with an Advan ced B eneficiary Notice of N on C overage (ABN) that Medicare would not pa y or was unlike ly to pa y for the item or service. While the time  limits  in 310 a pply for filing r equests for redetermination, ref unds  must be  made within the  time  limits sp ecified in Chapter 30.  An a dverse advance determination of  coverage under  1834(a)(15 ) of the Act is not a n initia l determination on a  claim for payment for items furnishe d and, ther efore, is not a ppeal able;   A non- participating physician not billing on an assigned basis but who m ay be responsible f or making a refund to t he beneficiary under 184 2(l)(1) of the Act for services furnishe d to a  beneficiary that are denied on the  basis of  sectio n 1862(a)(1 ) of the Act, has party status with respect to the  claim at issu e;   A provide r or suppli er who other wise does not ha ve the right to a ppeal ma y appeal w hen the  beneficiary dies and there is no othe r party available to appeal.  S ee 210.1 for information on determining  whether there is another party available to appeal;   A Medicaid S tate agency or party author ized to a ct on be half of the State. Medicaid State ag encies have party  status at the  redetermination level  (and subs equent levels) for claims for ite ms or services in volving a be neficiary who is e nroll ed to r eceive benefits unde r both Me dicare and  Medicaid, but only  if the  Medicaid State  agency has ma de payment for, or may be  liable  for su ch items or s ervices, and only i f the State  agency has fil ed a time ly request for re determination for such items or s ervices.  (See 42 C FR 405.90 8); and   Any individua l whose  rights with re spect to the  particular claim being reviewed may be aff ected by such review and any other individua l whose  rights with respect to suppl ementary medical insu rance benefits ma y be prejudiced by the decision (e .g., an individua l or entity liable for payment unde r 42 CFR subpar t E 424.60 i n the  case  of a deceased beneficiary).  Neither the contractor  nor CMS is considered a  party to an appeal  at the redetermination or  reconside ration levels, and theref ore does not ha ve the right to a ppeal or  to participate as a party at this sta ge in the  administra tive appeals p rocess.  CMS or a contractor may choos e to par ticipate in an ALJ hearing, become a party to an ALJ hearing (with C MS approval), or may r ecom mend that the  Administrative  QIC (AdQIC) refer an ALJ decision or  dismiss al to the Appeals C ounc il for rev iew unde r its own motion re view authority.  At tim es, an ALJ may ask for a contractors or QICs input to a  hear ing.  This doe s not c hange the contracto rs party status.  NOTE: While a representative may request an appeal on be half of the party that he/she re presents, the  representative is not a  party to the  appeal sol ely by virtue of being a re presentative.  (See 270 for the rights and responsibilitie s of a representative.) The provide r of the  item or service denied may represent the  individua l, but m ay not impose  any financial liability on the  individua l in connection with su ch representation.  If limita tion on li ability is involv ed, the  provide r of the item or service may represent the  individua l only if the provider waives any rights for payment from the  individua l with re spect to the  services or items involve d in the  appeal.   210.1 - Provider or Supplier Appeals When the Beneficiary is Deceased  (Rev. 695, Issued:  10- 07-05; Effective:  05 -01-05; Implementation:  01 -09-06)