(Medicare Claims Processing Manual)

 MACs sh all also ensure that appellants m ay save and pr int the  decision or  dismissa l noti ce and tha t the secure portal/application includes a mechanism b y which the  date/time  of the noti fication is trac ked/ma rked both in the  system and on any printed decision or dismissa l notices so a s to a dequately inform the  appellant of timef rames for ensuring timely submission of  future appeal requests.   If the MAC  receives a request for a case file from the  QIC, the MAC  shall provide  the compl ete cas e file including a  decision or  dismiss al noti ce regardless of whether the a ppeal w as processed via a  secure Internet portal/appli cation.   310.11 - Effectuation of the Redetermination Decision  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  All MACs are  responsible  for e ffectuating r edetermination d ecisions.  Eff ectuation m eans for the  MAC to adjust the claim and issue  a paym ent or to c hange  liability.  I f the redetermin ation decision is fully or partially  favorable  to the appellant and gi ves a specific  amount to be  paid, the MAC effectuat es within 30 c alendar da ys of the  date of the  redetermination d ecision. If the decision is fully  or partially  favorabl e, but t he payment amount must  be comput ed or recomput ed, the MAC e ffectuat es the decision w ithin 30 da ys aft er the payment amount is determin ed.  The payment amount must be  comput ed as soon as possibl e, but no lat er than 30 calendar da ys aft er the date of the  redeterminatio n decision.       310.12 - QIC Re mands (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  All MACs shall ta ke appropriate  action on r eview and r esolve QIC remands w ithin 60 c alendar da ys of receipt of the  remand orde r from  the QIC.  320 - Reconsideration - The Second Level of Appeal  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Section 1869 of the Act entitles any individual dissatisfied with the A/B MAC (A)s, (B)s, (HHH)s, or DME MACs redetermination to file a request, within 180 days of receipt of the redetermination, for a reconsideration.  In accordance with 1869(c) , reconsiderations are to be processed within 60 days by entities called qualified independent contractors (QICs).  CMS is required to contract with no fewer than four QICs.  When a claim is denied on the basis of 1862(a)(1)(A) of the Act, the QIC reconsideration will consist of a panel of physicians and other health professionals.  When the panel reviews services or items rendered by a physician or ordered by a physician, the panel will consist of at least one physician.   320.1 - Filing a Request for a Reconsideration  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  The request for a recons ideration m ade by a beneficiary, provider , suppli er, or State must be filed with the QIC specified in the redetermination notice.  A request from a provider, supplier, or State must be made in writing either on the Form CMS -20033 (the reconsideration request form included with the redetermination), or must contain the following items:    The beneficiarys name;   Medicare number ;   The specific service(s) and item(s) for which the  reconside ration is re quested and the sp ecific date(s) of service;   The name of the party or representative of the party filing the  request; and   The name of the contractor that made the redetermination.    A request from a  beneficiary must be  made in w riting either on a standard CMS form or anothe r written format indicatin g diss atisfaction with the  redetermination. R equests for reconsideration m ay be submitte d in sit uations wh ere beneficiaries assume  that they will r eceive  a reconside ration b y questioning a payment detail of the determination or  by sending additiona l information back with t he MSN or MRN, but don t actu ally say: I want a reconside ration. F or example, a written inqui ry stating, Why did you only pay $10.00?  is consid ered a  request for reconside ration. C ommon examples of phra sing in letters from be neficiaries that constitute re quests for reconsi deration:   Please r econsider my claim.    I am not satisfied with t he amount paid -  pleas e look at it again.    My neighbor  got paid f or the same kind of c laim. My claim should be p aid too.   The beneficiarys request may contain the  word appeal or  review. Th ere may be instances in whi ch the word review is used but wher e the clear intent of the request is f or a status re port. This should be  considered an inqui ry.  A. Re quest for Recon sideration (Form CMS-20033)   The CMS provide s a form for filing a request for reconside ration f or the conve nience of appellants, but a ppellants are not r equired to use  this form.  T he form is a vailable  on the C MS.gov website at:  http://www.c ms.gov/ Medicare/CMS-Forms/ CMS- Forms/Do wnloads/ CMS20033.pdf.  B. Requests Subm itted to the Wrong Co ntractor  Parties must re quest a reconsideration a t the QIC with ju risdiction.  C ontractors with multiple Sta tes may have multiple  QICs handling requests and, th erefore, must m ake certain to re fer the a ppellant to the correct Q IC.  The  jurisdiction f or all Part A Q IC appeals is d ependent upon the St ate where the service or item was rendered.  The jurisdiction f or all DME and P art B QIC appeals is d ependent upon the  State where the beneficiary resides. See 320.7 for the specific QIC jurisdictions.   There may be instances where requests for QIC reconside rations ar e misfiled with a  contractor. Contracto rs shall have standard operatin g procedures to e nsure that misfiled re quests ar e identifie d and s ent/transmitte d to the  proper location.  If the contractor receives a request for reconsideration from a party, or a request for reconsideration mistakenly directed to them by another contractor, and the contractor has already conducted a redetermination, the contractor sha ll forward the request to the appropriate Q IC, along with the  case file(s), within 60 cal endar days of receipt in the  corporate mailroom. The  case file must be  sent either by an el ectronic means agreed upon in the  JOAs or by a   courier service so tha t the case  file is re ceived by the QIC before or on the  61st cal endar day after the receipt.  C ontracto rs shall track all mis filed reconside ration re quests to e nsure receipt at  the proper QIC.  The  QIC will s end the  MAC  or DME MAC  an acknowl edgement of receipt of  any misfiled requests. C ontracto rs shall not c ount suc h mis filed requests as dismiss als. The  contractor counts the  costs a ssociated with mis filed requests in the  CAFM line  designated for preparing/transferring case files to the  QIC.  To aid in preventing misfiled re quests for QIC reconsiderations, c ontractors shall employ provide r education eff orts with a n empha sis on filing locations, as well as the  dates for workload transitions when a MAC jurisdiction is transferred from one contractor to the next at the close of a contracts period of performance.   NOTE:  If the contractor  receives a request for reconside ration  (assuming the appellant is using the wrong form or terminolo gy), but d etermines that a redetermination ha s not been c ondu cted, the contractor  does not f orward the  request to the  QIC. The  contractor shall conduc t a re determination.  320.2 - Time Limit for Filing a Request for a Reconsideration  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10 - 01-19)  A party must f ile a request for reconsi deration wi thin 180 da ys of the date of receipt of  the notice of the redetermination.  The date of filing for requests filed in w riting is defined as the date recei ved by the QIC in their corporate mailroom.  If the party has filed the  request in p erson with the  QIC, the filing date is the date of filing at such office, as evidenced by the receiving o ffices date stamp on the request.  If the party has mailed the request for reconside ration to a  CMS, SSA, RRB  office, or  another gover nment agency in good f aith within the  time  limit, a nd the re quest did not re ach the  appropriate QIC until af ter the time  period to file a request expired, the Q IC consider s the request as timely filed. Likewise, if the request is f iled with CMS, SSA, RRB , or anothe r government agency in pe rson, the  QIC consider s the request as time ly filed.  The QIC may extend the  period for filing if it finds the  appellant ha d good cause  for not re questing the reconside ration time ly.  (See 240 for a discussion of  good c ause.)  320.3 - MAC  Responsibilities - General  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  The contractors responsibilities for reconsiderations are:   1.  Preparing and forwarding case files upon request from a QIC in accordance with 320.4, 320.5, 320.6 and the JOA;     2.  Effectuating reconsiderations when notified by the QIC of a favorable decision or unfavorable decision with a change in liability in accordance with  320.8 and notifying the QIC of receipt of effectuation information;   3.  Preparing case files and forward misfiled reconsideration requests in accordance with  320.1(B); and  4.  Entering into JOAs with the appropriate QIC(s) and Administrative QIC (AdQIC); Complying with the appropriate JOAs.   320.4 - QIC Case File Development  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  When the  QIC receives a request for reconsi deration, it will re quest the  case file from the MAC  with ju risdiction using the Redetermination C ase File Request Form.  The  QIC will s end the  request either by email, telephone , fax, or by any other method a greed upon in the J OAs.  ( Note:  Individua lly identifiable beneficiary information should not be  given in a n uns ecure email.)  If another method is a greed upo n in the  JOAs, it mu st meet the  privacy requirements of  HIPAA.  If agreed upon in the  JOAs, the  following re quirements apply to email, fax and phone  requests:  (a) Email requests - MACs sh all ma intain an email account speci fically for the receipt of  case file requests from the  QIC.  If individually identifiable information is given in the re quest or respons e, a secure email account must be  used.  MACs must  check this e mail account a t least onc e daily (every business day).  When MACs r eceive email requests from the  QIC, they shall notif y the QIC of receipt.