(Medicare Claims Processing Manual)

340.3 - Requests for Case Files         (Rev. 4278, Issued: 04 -12-19, Effective: 06- 13-19, Implementation: 06- 13-19)          When the Appeals Council receives a request for review from an appellant, in most          instances it will not have a copy of OMHAs decision or dismissal, or the case file.  The Appeals Council will request all case files from the AdQIC.   340.4 - Payment of Interest on Appeals Council Decisions  (Rev. 985, Issued:  06- 16-06; Effective/Implementation Dates:  07 -17-06)  For guidance on how to make payment of interest subsequent to an Appeals Council decision, refer to chapter 3, of the Medicare Financial Management Manual, Pub. 100- 06.    345 - U.S. District Court Review - The Fifth Level of Appeal  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The circumst ances a llowing for an appeal or  escalation to the  U.S. Dist rict Court level of review are limite d, and ar ticulated in 42 C FR 405.1136.  345.1 - Requests for U.S. District Court Review by a Party  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Following issuance of a decision b y the App eals Counc il, a party may request judi cial re view of the  App eals C ounc ils decision.  A MAC  cann ot accept r equests for judicial re view.  The appellant must f ile the compl aint with the  U.S. District Court.  See 42 C FR 405.1136.  If a party files a request for judicial review with a  MAC, the  MAC  must imm ediately notify the appellant that the  complaint must be  filed with th e appropriate  U.S. Dist rict Court (i.e., the distric t court for the  judicial distric t in w hich the  party  resides or w here such indi vidual, institution, or age ncy has its prin cipal pla ce of bus iness).  However, t he appellant is r esponsible for d etermining w here the complaint must be  filed.  MACs shall not f orward the  complaint to a distric t court as a c ourtesy to the  appellant.   The amount re maining in controversy must meet the required threshold.  C urrent amount in controve rsy threshold figure  available  on the  CMS website  at: http://www.c ms.gov/ Medicare/App eals-and-Grievances/Org MedFFSApp eals/Review-Federal- Distric t-Court.html .  See 250.    If a MAC  receives a copy of a summons or  complaint for judi cial review in federal distric t court, a nd it doe s not a ppear  that a copy was sent to the  following address, the MAC  shall send the original to:  Department of Health a nd Hum an Services General Couns el 200 Independence Avenue, S.W. Washing ton, D.C . 20201   The MAC  retains a copy and noti fies its C ontra cting Offi cers Representative  (COR) immediately.  T he CMS COR should al ert the CMS Central Office C ouns el that a c omplaint has b een for warded by the  MAC to the HHS  General C ouns els offi ce.  345.2 - Effectuation of U.S. District Court Decisions  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The U.S. Dist rict Court may remand the  case  to the App eals C ounc il or ALJ for further proceedi ngs.  In rare cases, the  U.S. Dist rict Court will issue  an order that will require effectuation b y a MAC.  In this situ ation, the  MAC  immediately contacts its C ontra cting Officers Representative /Contra ctor M anag er for further instructions bef ore taking a ny action.  345.3 - Payment of Interest of U.S. District Court Decisions (Rev. 862, Issued: 02- 17-06, Effective: 05 -01-05, Implementation: 03- 17-06)  For guidance on how to make payment of interest subsequent to a U.S. District Court decision, refer to chapter 3 of the Medicare Financial Management Manual, Pub. 100 -06.  350 - Workload Data Analysis  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Data analysis involves collecting relevant data, analyzing the data, identifying trends and aberrancies, and making conclusions based on the data collected.  Data analysis should be performed, as needed, at all relevant operational sites to identify ineffi ciencies or problems with appeals.  Within the constraints of the current operating environment, MACs should work to address and resolve concerns.  Significant issues should be raised to CMS, preferably through the COR or Contract Manager.   360 - Managing Appeals Workloads  (Rev. 675, Issued: 09- 16-05, Effective: 10 -01-05, Implementation: 10- 03-05)  360.1 - Standard Operating Procedures  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The priorities set forth in this s ection ar e to be  used by MACs  as a guide in establishing standard ope rating procedures for managing an appeals wo rkload when the  budg et amount is   insuffi cient to a dequately perform the  required functions.  In general, MACs should use  a first-in, first-out m ethod to pr ocess a ppeals a nd m anage workload; how ever, during times of limite d resources it ma y become  necessa ry to prioritize the processing  of appeals to mo re efficiently manage the workload.  W hile CMS continue s to recomm end the priorities liste d in this s ection, there may be instances wh ere MACs f ind it mo re effective  and eff icient to pr ioritize in a different manner.  Also, MACs  may choose  to establish s tandard ope rating procedur es for managing an appeals wo rkload tha t deviate from the priorities listed in this s ection.  In both these cases, MACs should submit a  copy of their prioritization pl an to the Contra cting Offi cers Representative /Contra ctor M anag er and obt ain written approval for this v ariation within 30 days of the  start of  the fiscal year or period of pe rform ance.  360.2 - Execution of Workload Prioritization  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Budget Related Workload Prioritization  Whenever it appears that the budget amount is insufficient to adequately perform the required functions and the need for additional funds can be adequately documented, MACs shall submit a Supplemental Budget Request (SBR) in accordance with the IOM Pub. 10 0-06 Medicare Financial Management Manual, chapter 2 120.  As a result of an SBR, or during the course of CMS' evaluation of an SBR, CMS may find it necessary that the MAC execute prioritization of workload in accordance with this section or in accordance  with the MACs standard operating procedures.  The MAC should discuss possible alternatives for resolution in the SBR.  If it becomes necessary to abate activities, MACs must submit proper notification in accordance with the terms of the Cost of Administr ation Article in the Contract/Agreement and begin processing work in accordance with this PM until a final agreement is reached between the MAC and CMS.  As a result of an abatement, CMS may find it necessary that the MAC continue processing work in accordance with this manual instruction.   B. Other Circumstances That May Lead to Workload Prioritization   In circumstances other than those described above, it may become apparent that prioritization of workload is necessary because a MAC is unable to complete the incoming or pending workload within the time frames described in this manual.  In these situation s the MAC must either consult with the COR immediately for guidance or notify the COR that they plan to initiate their workload prioritization plan.  An example of a situation that may lead to workload prioritization is an uncharacteristic, unanticipated i ncrease in receipts over a two -month period, coupled with, insufficient staff or other resources that will impede you from completing the increased volume of appeals receipts in a timely manner.        360.3 - Workload Priorities  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Priority 1 - Finalize effectuation of all redetermination, reconsideration, ALJ and Appeals Council decisions and process redeterminations and forward reconsideration case files to the QIC timely on overpayment determinations (including CERT contractor appeals).  Priority 2 - Prepare, assemble, and forward case files to the QIC in accordance with the timeframes described in 320.6  Priority 3 - Adjudicate redeterminations from beneficiaries or their appointed beneficiary representatives in the timeframes described in 310.4.  Priority 4 - Adjudicate requests for redeterminations from providers, suppliers, or other appellants, including States or their third party agents, that are submitted with necessary documentation in the timeframes prescribed in 310.4.  Priority 5 - Adjudicate written requests for redeterminations from providers, suppliers, or other appellants, including States or their third party agents, that are submitted without  necessary documentation in the timeframes prescribed in 310.4.      Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 01/04/2024  13222  R4380CP  08/30/2019  Pub. 100- 04, Chapter 29  Appeals Signature Requirement Changes  10/01/2019  11352 R4278CP  04/12/2019  Pub. 100- 04, Chapter 29  Appeals of Claims Decisions -  Revisions  06/13/2019  11042 R3549CP  06/24/2016  Pub. 100- 04, Chapter 29  Appeals of Claims Decisions Update: Revisions to Timeliness Requirements for Forwarding Misfiled Appeal Requests, Reconsideration Request Form, and Guidelines for Writing Appeals Correspondence  07/26/2016  9600 R2926CP  04/11/2014  Chapter 29 Appeals Update (Includes Post -DOMA Guidance and Signature Requirement for Appointment of Representatives and Assignment of Appeal Rights)  07/14/2014  8588 R2729CP  06/21/2013  Appeals Revisions -Final Regulation  07/23/2013  7840 R1986CP  06/11/2010  Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Appeals Via Facsimile and/or Via a Secure Internet Portal/Application  10/01/2010  6958 R1965CP  05/07/2010  Appeals Revisions -AIC Requirements  08/09/2010  6894 R1878CP  12/18/2009  Revisions in Timeliness Requirements for Forwarding Misfiled Appeal Requests  01/19/2010  6701 R1762CP  07/02/2009  Appeals Revisions  08/03/2009  6377