(Medicare Claims Processing Manual)

3.  Requesting Documentation for Beneficiary -Initiated Appeals   For beneficiary initiated appeals, when necessary documentation has not been submitted, the reviewer advises the provider or supplier to submit the required documentation.  The reviewer documents the request in the redetermination case file.  The reviewer notifies the beneficiary (either in writing or via a telephone call) when the reviewer has asked the beneficiarys provider or supplier for additional documentation.  The reviewer also notifies the beneficiary that the provider or supplier has 14 calendar days to submit the additional documentation that has been requested, and that if the documentation is not submitted, the reviewer will decide based on the evidence in the case file.  If the reviewer sends the beneficiary a letter, it must include a descrip tion of the documentation that has been requested. The reviewer shall document all notifications and correspondence to and from the beneficiary in the redetermination case file.   4.  Extension for Receipt of Additional Documentation   Contractors shall educate parties to include all supporting documentation with the redetermination requests submitted via mail, facsimile or a secure Internet portal/application. However, when a party submits additional evidence (via mail, facsimile or a s ecure Internet portal/application) after filing the request for redetermination, the contractors 60 -day decision-  making timeframe is automatically extended for up to 14 calendar days for each submission.   This additional time is allowed for all documentation submitted by a party after the request, even when the documentation was requested by the contractor.  Although this extension is granted to the contractor for making decisions, it should not routinely be applied unless extra time is needed to consider the additional documentation. 5.  General Information   The contractor routinely includes instructions on the appropriate information to submit with appeal requests in its provider newsletters and other educational literature.  Providers and suppliers are responsible for providing all the information the contra ctor requires to adjudicate the claim(s) at issue.   310.5 - The Redetermination Decision  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  A.  Redetermination  Decision Letters  The law requires contractors to c onclude and m ail and/or  other wise transmit the  redetermination decision within 60 da ys of receipt of  the appellant's re quest, as indi cated in 310.4.  For unfa vorable redeterminations, the  contractor  mails the decision le tter to the  appellant, and m ails copies to each party to the initia l determination ( or the partys author ized representative and/or a ppoint ed representative, if applicable).  Contracto rs shall mail the  written decision unl ess the  contractor has received approval from C MS to use  a secure Internet portal/application a s part of the appeals process and the appellant has submitt ed the  request for appeal e lectronically.  Contracto rs may transmit a ppeal d ecisions (fa vorable, partially favorable, or unfavorable) via a secure Internet portal/application if  the a ppeal r equest was received via  that mech anism. Contra ctors shall e nsure  that a hard c opy decision l etter is s ent to othe r parti es to the  appeal who do not ha ve access to the  secure  Internet portal/appli cation.  S ee 310.10 for additional r equirements related to noti ces sent via s ecure portal/ appli cations.   For partially favorable redeterminations, the  contractor  mails and/or  otherwise transmits the d ecision le tter, and an a djusted MSN or RA to the  appellant.  T he contra ctor mails a c opy of the decision l etter and mails or otherwise transmits a n adjust ed MSN or RA to eac h party to the initia l determination ( or the partys authorized representative, if applicable). The  contractor shall ensure that the appropriate MSN or RA messages are included regarding refunds of  payments, inc luding when necessary any coinsura nce or deductible collected.  If a party has an appoint ed representative, the contractor  mails the  decision l etter to the  appoint ed representative (see 270 ).  Sending the decision l etter to the  appoint ed representative has the s ame force and effect as if the letter was sent to the  party. The  contractor does not s end an MSN or RA to a n appoint ed representative.  For fully favorable redeterminations, the  contractor mails or oth erwise transmits a n MSN or RA ref lecting the adjustm ent action to each p arty (or the partys authorized representative, if applicable) on the  next scheduled release.  The MSN provide s the beneficiary with in formation a s to his/h er financial liability with regard to the  claim(s) that are now payable (e.g. appli cable c oinsuranc e).  The contractor  does not s end an MSN or RA to a n appoint ed representative.  Unless oth erwise specified in its sta tement of work, contracto rs are not r equired to s end a fully favorable letter to par ties until f urther notice, except in those  situations wher e the parties will not rece ive notice of effectuation via  an MSN or RA (e.g., MSP over payments, non-MSP over payments whi ch do not re sult in a  refund or  payment, etc.).  In the se cases, the  contractor m ails and/or  other wise transmits via  secure Internet portal/application a  notice to suc h par ties or a uthorized/appoint ed representative if applicable, that references the claims appeal ed, and br iefly explains the  outcome of the redetermination.  B.  Determinations That Result in Refunds to a  Beneficiary  If, as the result of  a denial, a provide r or suppli er is required to m ake a refund to a  beneficiary for amounts collected from t he beneficiary for the items or  services at issu e, then the  contractor must in clude the following language in the  redetermination:  Therefore, you (the beneficiary) are not re spons ible for the charges bille d by (provide r's name) except for any charges for services n ever covered b y Medicare.  If you (the b eneficiary) have paid (provide r's name) for these services (including payment of co- insura nce and de ductible), you m ay be entitle d to a refund.  To get this ref und, pl ease contact this o ffice and send the following items:   A copy of this noti ce,  The bill you received for the services, and  The payment receipt,  your canc elled check, or  any other evidence showi ng that you have already paid (provide r's name) for the services a t issu e.  You should f ile your written request for refund within 6 months of  the date of this noti ce.  If, as the result of  a denial, a provide r or suppli er is required to m ake a refund to a  beneficiary for amounts collected from t he beneficiary for the items or  services at issu e, then the  contractor must s end a copy of the adjust ed RA in the  following  situations:   1.  A nonpar ticipating physician not a ccepting a ssignment who, b ased on t he redetermination, now h as a refund obl igation unde r 1842( l)(1) of the Act;  2.  A nonpar ticipating suppli er not acc epting a ssignm ent who is de termined to ha ve a refund obli gation pursuant to 1 834(a)(18 ), due  to a denial unde r either 1834( a)(17)(B ) or 1834( j)(4) of the Act; or,  3.  A de nial based on 1879( h) of the Act of an assigned claim submitte d by a suppli er, where it is determined unde r 183 4(a)( 18) of the Act that the suppli er must ref und a ny payments (including deductibles and coinsu rance) collected from the  beneficiary.  NOTE:  For additional i nformation r egarding r efund r equirements, pl ease refer to IOM 100- 04 C hapter 30, sections 140 and 150.  C.  P aid Claim Appeals  If a contractor  receives a valid appeal r equest on a  claim th at was processed and pa id subs equent to the  filing of that appeal but pr ior to issu ance of the Medicare Redetermination Noti ce, the c ontractor  shall issue  an unfavorable decision l etter using the following template or som ething simila r to the  appellant:  (Start) EXHIBIT 1:      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>   Dear <Appellant Name>:   This letter is to inform you of the decision on your Medicare appeal.  An appeal (also known as a redetermination) is a new and independent review of a claim.  You are receiving this letter because you requested a redetermination for <SERVICE(S)> on <DATE( S)>.  The redetermination decision is unfavorable because the service(s) in question has(have) already been paid by the MAC on <DATE>.  We have evaluated the information submitted and there do not appear to be any errors impacting the payment amount, which Model Redetermination  Unfavorable Decision for     Paid Claim  Appeal  is the maximum allowed by Medicare for this service.  As a result, we are issuing an unfavorable decision on your request for a redetermination on this claim.  If you disagree that the claim in question was previously processed for payment, and/or you otherwise disagree with this decision, you may appeal to a Qualified Independent Contractor.  You must file your appeal, in writing, within 180 days of receipt of t his letter, to the following address:  [INSERT QIC INFORMATION]   Sincerely,    NAME, TITLE  CONTRACTOR NAME   (End)  Exhibit 1      310.6 - Dismissals (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Contractor Di smissal of  a Redetermination Request The contractor may dismiss a request for a redetermination unde r the following  circumst ances:  1. Request of a Party - A request for redetermination m ay be withd rawn at any time prior to the mailing or transmission of  the decision via  a secure Internet portal/application upon the  request of the party or parties filing the request for redetermination.  A par ty may request a dismiss al by filing a written noti ce of such request with the  contractor.  C ontracto rs may accept requests for withd rawal via facsimile  and/or  a secure Internet por tal/application, if  approved by CMS.  The dismiss al of a request for redetermination is binding unless vacated by the contractor or Q IC.  2. Dismiss al for Cause - The contractor may dismiss a redetermination re quest, either entirely or as to any stated issu e, under either of the followi ng circumst ances:  a) Where the party requesting a redetermination is not a  proper party, or  b) Where the party  requesting a r edetermination doe s not other wise have a right to a redetermination.  3. Failure to File Tim ely - When a request for redetermination is not f iled within the  time  limit required, and the  contractor did not f ind g ood c ause for failure to file timely, it should dismi ss the request.  4. Appointm ent of Representative is D efective  - When an indi vidua l who is a ttempting  to act a s a representative of an appellant who is not the  beneficiary submits an in compl ete appointm ent form and the  appointm ent is not correc ted within t he time  limit dis cussed above  in 270.1.6.B.1, the contractor  dismisse s the request.  NOTE:   If the appellant resubmits a n appeal r equest with a n appointm ent of representative form, the  contractor should c onsider the request as a duplica te and should not c ount the  resubmission a s additiona l workload. (See Pub. 100- 06, the  Medicare Financial Management M anual, Chapter 6.)