(Medicare Claims Processing Manual)

B. Duration of Appointment   The duration of the appointment lasts until revoked by the beneficiary absent specific language in the appointment document limiting the duration of appointment.  This is true regardless of whether or not an appeal has been filed within 1 year of the date of the appointment.  C. Correspondence  Both the beneficiary and the representative shall receive copies of all correspondence (including all appeals determinations).   D. Death of a Beneficiary   The death of the beneficiary terminates the authority of any representative appointed by the beneficiary.  The representative must obtain a new appointment from the beneficiarys estate or the individual assuming responsibility for the estate if there is no formally appointed executor.   280 - Fraud and Abuse  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  280.1 - Fraud and Abuse - Authority  (Rev. 2926, Issued: 04- 11-14, Effective: 07 -14-14, Implementation: 07- 14-14)  To protect the Medicare program from fraud and abuse, civil and criminal violation provisions have been included in 1107, 1128A , 1128B , 1872, and 1877 of the Act.   280.2 - Inclusion and Consideration of Evidence of Fraud and/or Abuse  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The MAC sh all inq uire fully into the  matters at issue  by receiving, in e vidence, the t estimo ny of witnesses and any documents th at are relevant to the  claims a t issu e.  If the MAC  believes that evidence has been t ampered with, it sh all refe r this documentation to e ither the medical review or the UPIC s units f or their follow -up.  The MAC  may receive evidence obtained and provide d by the UPIC c oncerning fraud or pot ential fraud with re spect to the  claim(s) at issu e.  If the UPIC p rovide s such evidence, it becom es part of the case file and must be  made available for inspe ction b y the appellant prior to the  reconside ration.  Evi dence of this nature  is to  be evaluated to de termine issues such as wh ether, in c onjunc tion with oth er credible  evidence, the services in que stion w ere actually provide d or were provided as bille d.  NOTE:  See 300.3 for additional informa tion regarding fraud and abuse  investigations.   280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Where there is a subst antial basis for determinin g tha t an item or service either was not f urnished or  was not furnishe d as billed, the  MAC  may deny or down -code payment, as appropriate.  The  reviewer must e nsure that the case file clearly documents the  evidence that formed the  basis for the determination.  Appeal r ights after such a determination re main the  same as they would f or any other unfavorable decision.  I f the MAC  has reason to be lieve or evidence to suppor t that items or  services w ere not furnishe d or were not furnishe d as bille d, it sha ll send a copy of the  decision to its UPIC .    280.4 - Responsibilities of Adjudicators  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If, during the course of the redetermination, the  reviewer susp ects a civil or  criminal law viol ation, the  reviewer shall render a decision onl y on the  coverage or payment issu es raised by the  redetermination request.  Althoug h the  reviewer cannot m ake a determination of  civil or cr iminal fraud, h e/she may still d eny or reduce payment if he/she believes that the items or s ervices a t issue  were not re ndered, or were not rendered a s bille d (as discussed above) .  In making this d etermination, the  reviewer may conside r all available evidence that is in cluded in the  case fil e, including w itness testimo ny, medical recor ds, and evidence compile d through a fra ud inve stigation, a s discussed above .  (See 310.4.B  below.)   In addition to denying the claims b ecause  the services were not re ndered as bille d, if the reviewer suspects f raud, he /she shall forward information r egarding the potential civil or  criminal viol ation to the  UPIC .  For further discussion on M edicare fraud issue s, refer to the  Medicare Program Integrity Manual, IOM 100- 08, Chapt er 4.  280.5 - Requests to Suspend the Appeals Process  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The MAC  does not h ave the author ity to suspe nd re determinations a t the request of the Office of the Inspector  General  (OIG) or the Department of Justice (DOJ) without a pproval and di rection from C MS central office (CO).  If the OIG or DOJ  submits a  request to susp end a r edetermination, the  MAC  shall first bring that request to the  attention of  CO through the RO.  280.6 - Continuing Appeals of Providers, Physicians, or Other Suppliers Who are Under Fraud or Abuse Investigations  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  Reviewers shall continue adjudicating the appeals of Medicare claims submitted by a provider, physician, or other supplier who is being or has been investigated, indicted, or convicted for fraud or abuse on other Medicare claims, or who is on Medicare paym ent suspension, unless the MAC has been informed that the provider, physician, or other supplier has agreed, as part of a settlement with the Government, or as the result of a prosecution, to withdraw the appealed claims or to waive the right to appeal the  subject claim(s).  If it has received notice of such a settlement, the MAC shall dismiss the appeal based on the fact that the appellant has waived his/her/its right to an appeal, and/or agreed to withdraw appeal of these claims as part of a settlement ag reement with the Government.  The MAC places a copy of the settlement document or other evidence of a settlement in the file.  A reviewer shall remain neutral in the adjudication of claims that involve a provider, physician, or other supplier who is being or has been investigated, indicted or convicted of fraud or abuse.   280.7 - Appeals of Claims Involving Excluded Providers, Physicians, or Other Suppliers  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  The appeals process remains in eff ect for all claims with s ervice dates prior to the  effective  date of exclusion. An e xcluded provider , physician, or suppli er, or the  beneficiary may appeal such claims.  I n addition, if t he billing pri vileges of a pro vider, phy sician, or s upplier are revoked retroactively, and the  contractor re opens pr eviously paid c laims to ass ess an o verpayment against the  exclude d par ty, the  excluded party  (or the beneficiary) may  appeal the  revised initial d etermination and ove rpayment unde r the claims appeal pro cess (42 CFR part 405 subpart I ).  NOTE:  A pro vider or su pplier's app eal of a r evocation or de nial of bil ling p rivileges is pro cessed in accordanc e with the  procedur es set forth in 42 C FR part 405 subpart H  and 42 C FR part 498 ( see also, I OM 100-08, C hapter  15, 15.25) . The contra ctor is bound by the  terms of the  revocation a ction unl ess billing privileges are r einstate d und er the enrollm ent appe als pro cess.    290 - Guidelines for Writing Appeals Correspondence  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The guidelines in this section are to be used when preparing appeals correspondence, which includes redeterminations decisions and inquiries about the status of appeals.  These shall be handled as expeditiously as possible without lowering the quality of t he response.  General instructions on responding to beneficiary and provider/supplier communications are found in CMS Medicare Pub. 100- 09.  All other CMS -issued instructions on correspondence guidelines apply as well, including instructions on corresponde nce letterhead requirements.   290.1 - General Guidelines  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  MACs sh all prepare appeals c orrespond ence so the  appellant can easily understand both the reason w hy any of the services w ere not c overed or could not be  fully reimbur sed, and wha t action the  appellant can take if the appellant dis agrees with th at decision.  In addition, the g uidelines listed here should be  follow ed to the  extent possibl e:   Keep the  language as simple  as possibl e;   Do not use  abbreviations or  jargon;   Choose  a positive  rather than a negative tone , whenever possibl e.  Avoid w ords or phra ses that empha size what cannot be  done by the MAC  or the appellant;   If possibl e, avoid one  sentence paragraphs, une ven spacing be tween paragraphs, e tc.;   Apolog ize when appropriate, e.g., if the response  is late.  How ever, do not a polog ize for enforcing Medicare guidelines that may be adverse to the  appellants claim;   Summ arize the question bef ore providing a  response; and,   Use correct sp elling, grammar , and punc tuation.  290.2 - Letter Format  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Appeals c orresponde nce shall follow the  instructions issu ed by CMS for MAC  written correspon dence letterhead re quirements unl ess otherwise instructed and/or  agreed to b y CMS.  In addition, observe the following information:    Num erical d ates must not be  used (i.e., inst ead o f 6/16/13, use  June 16, 201 3), except when included in a table;    Type/font si ze must be  12 point or large r (all respons es are to be processed using a  font si ze of 12 and a font style of Univ ersal or Times New Roman or similar style for the ease of reading by the beneficiary and the provider) ;   When the  subj ect ma tter is lengthy or compli cated, bull et points should be  used to c larify, if possibl e;   For long letters, headings should be  used to break i t up (e .g., DECISION, BACKGR OUN D, R ATIONA LE);   If procedure codes are cited, the  actual name of the procedu re must be  associated with the  code;   Span dates may not be  used for 1 da y of service; and   The MAC  should no t use all capit al letters.  Letters that contain all capital letters appear impersonal and comput er generated.  Refer to 300.5 f or instructions on how to ha ndle cases involving multiple  beneficiaries, inc luding overpayment cases involving multiple  beneficiaries.  290.3 - How to Establish Reading Level  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The MMA requires that appeals correspondence be written in a manner calculated to be understood by beneficiaries.  MACs shall write appeals correspondence that is understandable to beneficiaries.  The purpose of this section is to provide some guidance to MACs on writing letters that are easy for beneficiaries to understand.  To achieve this goal, MACs shall:  (1) Write in plain English/plain language with a clear, simple, conversational writing style with good communication of key points.