(Medicare Claims Processing Manual)

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)  When a provider or supplier appeals on behalf of a deceased beneficiary and the provider or supplier otherwise does not have the right to appeal, the MAC must determine whether another party is available to appeal by taking either of the following actions:    The MAC may send a letter to the last known address of the beneficiary, or to the beneficiary's estate, if known.  The letter should advise the beneficiary's estate (or anyone taking responsibility for the deceased's bills for medical or other health servi ces) of the right to appeal the claim denial.  The letter also should provide information that the provider or supplier wishes to appeal.  The letter should provide the beneficiary's estate with the following three options:   o Option 1: I wish to appeal this claim.   o Option 2: I am not available to appeal, please process the provider's appeal and let me know   of the result.   o Option 3: I am available to appeal, but do not wish to exercise my right to appeal.   The MAC should allow the estate at least 10 days to respond, or the remainder of the time frame for requesting an appeal --  whichever is greater.  If the estate does not respond in the allotted time frame, the MAC should annotate the file that no other par ty is available to appeal and continue to process the provider's or supplier's appeal.  If the estate responds that it is available and wishes to appeal, the MAC should continue with the appeal and notify the provider or supplier of the results.  If the estate indicates that it is not available to appeal, then the MAC s hould continue to process the appeal and notify the beneficiary's estate of the decision.  If the estate indicates that it is available, but does not want to appeal, the MAC should dismiss the provider or supplier's request on the basis that there is another party available, even though the party does not intend to pursue the appeal; or   The MAC may send a letter to the provider or supplier to request written confirmation that they are not aware of any other party available to appeal.  The MAC should allow the provider or supplier 10 days to provide confirmation.  If the MAC does not recei ve written confirmation within 15 days, it should dismiss the appeal on the basis that the provider or supplier did not confirm that there was no other party available to appeal.   220 - Steps in the Appeals Process:  Overview  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Regulations a t 42 C FR 405.940- 405.942 pr ovide  that a party to a redetermination th at is diss atisfied with an initia l determination m ay request that the contractor make a redetermination. The  request for redetermination must be  filed within 120 da ys after the date of receipt of  the noti ce of the initia l determination ( the notice of initia l determination is p resumed to be  received 5 da ys after the date of the notice unless there is evidence to the contrary). Contracto rs cannot acc ept an appeal for which no initi al determination ha s been m ade. The  parties specified in 210 who ar e dissatisfied with a  determination on th eir Part A or  B claim have appeal rights.  The appeals process consists of  five levels. The  appellant must b egin the appeal at the first level after receiving a n initia l determination. E ach l evel, after the initia l determination, ha s procedura l steps the  appellant must ta ke before appealin g to the  next level. Each l evel is dis cussed in de tail in subs equent sections. I f the appellant meets the procedu ral steps at a specific level (including the  amount in controve rsy (AIC) requirement if appli cable), the appellant (and all oth er parties to the  appeal decision)  is th en afforded the right to a ppeal any determination or decision to the  next level in the  process. The  appellant may exercise  the right to a ppeal a ny determination or  decision to the  next higher level, until a ppeal r ights are exhausted. Althoug h ther e are five distin ct levels in the  Medicare appea ls process, the  redetermination, l evel 1, is the only level in the  appeals  process th at the contractor performs.  When an appellant requests a reconside ration with a  QIC (level 2), the contractor  must p repare and forward the case file to the  QIC.  Further, the contractor  may have effectuation re sponsibilitie s for decisions m ade by the QIC. The contractor, how ever, does not ha ve re sponsibili ty for reviewing the QICs decision f or accur acy. When an appellant requests an Administ rative Law Judge  (ALJ) hearing or review by an attorney adjudicator (level 3), the QIC must p repare and forward the  case file to the  OMHA.  Further, the contractor may have effectuation r esponsibilitie s for decisions m ade at OMHA, D epartmental App eals Board (DAB)/Appeals C ounc il, and Fe deral C ourt levels.  In the  chart below, l evels 1  4 ar e part of the Administra tive App eals P rocess.  If an appellant ha s compl eted all the  first 4 st eps of  the administra tive appeals process and is still d issatisfied, the  appellant may appeal to the Federal courts, pr ovided the  appellant satisfies the requirements for obtaining judicial review.   CHART  1 - The Med icare Fee-for-Service Appeals P rocess  APPEAL LEVEL TIME LIMIT FOR FILING REQUE ST MONETA RY THRESHOLD TO B E MET 1. Redetermination 120 d ays from d ate of receipt of the  notice initia l determination None  2. Reconsid eration 180 d ays from d ate of receipt of the  redetermination* None  3. Administ rative Law Judge (ALJ) Hearing 60 days from the  date of receipt of the  reconside ration Current AIC requirements can be  found on CMS.gov at: http://www.c ms.gov/ Medicare/Appeals-and-Grievances/Or gMedFFS Appeals/HearingsA LJ.html .  See 250 for additional information.  4. Departmental Appeals B oard (DAB ) Review/App eals Council 60 days from the  date of receipt of the  ALJ hearing decision  None  5. Federal Court Review 60 days from d ate of receipt of the Appeals C ounc il decision Current AIC requirement can be  found on CMS.gov at: http://www.c ms.gov/ Medicare/Appeals-and-Grievances/Or gMedFFS Appeals/Review-Federal-Distric t-Court.html .  See 345 for additional information   *NOTE: If a party  requests Q IC review of a contra ctors dismissal of a r equest for re determination, the  time  limit for f iling a r equest for reconside ration is 60 da ys from the  date of receipt of the  contra ctors dismissal notice.  230 - Where to Appeal  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Where a party must f ile an appeal d epends on the  level of appeal.  The  chart below indi cates wh ere appellants should f ile appeal requests for each l evel of appeal.  CHART  2 - Where to File an Appeal  LEVEL  WHERE TO F ILE AN AP PEAL    Part A*  Part B  DME   Redetermination  MAC   MAC   MAC  LEVEL  WHERE TO F ILE AN AP PEAL   Reconsid eration  QIC   QIC   QIC   ALJ H earing  HHS OM HA Ce ntral Operations    HHS OM HA Ce ntral Operations    HHS OM HA Ce ntral Operations    Appeals Coun cil Review  Appeals Coun cil  Appeals Coun cil  Appeals Coun cil  *Includes part B claims f iled with the  Part A  Medicare Administrative  Contra ctor (M AC).  240 - Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. T ime Limits for Each Level of Appeal The time  limits f or filing appeals va ry according to the  type of appeal:   Redetermination - The time  limit f or filing a request for redetermination is  120 da ys from the  date of receipt of  the Medicare Summ ary Notice (MSN) or Remitta nce Advi ce (RA).  See 240. 1-240.5 f or clarifications  and exceptions to this rule.)   QIC Recon sideration - The time  limit f or filing a request for reconside ration is 180 da ys from the  date of receipt of  the notice of the redetermination.  I f a party requests Q IC review of a MACs dismissal of a r equest for re determination, the  time  limit for filing is 60 da ys from  the date of receipt of the  MACs dismissal noti ce.   ALJ Hearing - The time  limit for filing a request for an A LJ hearing is 60 days from the  date of receipt o f the reconsidera tion not ice.   Appeals C ounc il Review - The time  limit f or filing a  request for re view by the Appe als C ounc il is 60 da ys from the  date of receipt of the ALJs or attorney adjudicators de cision.   Judi cial R eview - The time limit f or filing for judicial review is 60 da ys from the da te of the Appeals C ounc il's decision.  A request filed with the  A/B MAC (A), (B), (HHH), or DME MAC is c onside red to have been filed as of the date the MAC recei ved it.  The  MAC  comput es the time  limit f or requesting a redetermination b y allowin g 5 additiona l days beyond the time  limit ( 120 da ys for a redetermination)  from the  date of the p revious noti ce.  This a llows a  5-day period for mail delivery.  The  MAC  allows f or addition al time  if there is evidence that the mail delivery was longer than 5 days.  NOTE:  When the beneficiary preference is to have all documents converted into an accessible format, MACs shall make allowances for additional delivery time of the accessible format. The MAC shall also provide allowance for a delayed response as a result of a beneficiary having sought and received help from an auxiliary resource (such as a SHIP or senior center), on account of his or her disability, in order to be able to file an appeal (also see 240.2).   When the  filing d eadline  for a re determination e nds on a Saturda y, Sunda y, legal holida y, or any othe r nonw ork day, the  MAC shall apply a r ollover period that ex tends the  filing de adline to the  first w orking day after the Saturda y, Sunda y, legal holida y, or othe r nonw ork day.  For ex ampl e, if the  filing d eadline  for a redetermination falls on the  Saturday  before Columbus Da y, the  filing d eadline  is ex tended to the  first working day after the Columbus Day holida y.