(Medicare Claims Processing Manual)

DECISION  <Instructions: Insert a brief statement of the decision, for example "We have determined that (the specific items/services) are not covered by Medicare. We have also determined that (the provider) (the supplier) (the beneficiary) is responsible for the cost of the item(s)/service(s).">   EXPLANATION OF THE DECISION     <Instructions: This is the most important element of the redetermination. Explain the logic/reasons that led to your final determination. Explain the coverage policy (LCD, NCD), regulations, policy guidance (IOM provisions), and/or laws used to make this determination. Make sure the rationale for the decision is clear and that it includes an explanation of why the claim can or cannot be paid for the particular set of facts at issue in the appeal. For example, the explanation should demonstrate how the benef iciarys condition or circumstances do not meet specific coverage policy requirements. Statements such as "not medically reasonable and necessary under Medicare guidelines" or "Medicare does not pay for X" provide conclusions instead of explanation, and ar e not sufficient to meet the requirement of this paragraph.>   WHO IS RESPONSIBLE FOR THE BILL?   <Instructions: 1. Include, as applicable, information on limitation on liability under 1879 of the Act, physician refund requirements for non- assigned claims under 1842(l) of the Act, DMEPOS supplier refund requirements under 1834 and 1879(h) of the Ac t, financial responsibility for benefit category denials (statutory exclusions), and waiver of overpayment recovery under 1870 of the Act.   For example, if the denial reason triggers a liability determination under 1879 of the Act, include the following model paragraphs:   After determining that the item or service will not be covered by Medicare, we must determine who is financially liable for the denied item or service. When an item or service is denied under 1862(a)(1), 1862(a)(9), or 1879(g) of the Social Security Ac t (the Act), we must determine if the beneficiary and the provider or supplier either knew or could reasonably be expected to know that the item or service would not be covered. This is known as the limitation on liability provision of 1879 of the Act.   If the beneficiary was informed by their provider or supplier in writing in advance of receiving the item/service that Medicare may not make payment (through receipt of an Advance Beneficiary Notice of Noncoverage (ABN)), the beneficiary may be responsible for the cost of the denied item or service. If the provider or supplier knew or could reasonably be expected to know the item or service would not be covered, but the beneficiary did not have such knowledge, then the provider or supplier may be responsibl e for the cost of the denied item or service.   2. Include, as applicable, a statement regarding beneficiary knowledge of non- coverage and a statement regarding provider/supplier knowledge of non- coverage when liability under 1879 of the Act is at issue. If the provisions of 1879 of the Act do not apply to the coverage denial, then do not include a discussion of 1879 in the redetermination letter.  For additional information regarding the application of 1879, see IOM 100- 04, Ch. 30, 10- 30.  Beneficiary model paragraphs for 1879 analysis     (Beneficiary Option 1) We have determined that the beneficiary either knew or could reasonably be expected to know that the service/item would not be covered because [insert reason for determining that the beneficiary knew or could have been expected to know the item/service would not be covered; typically this is established when the provider/supplier delivers a validly executed ABN].   (Beneficiary Option 2) There is no evidence to indicate that the (provider) (supplier) notified the beneficiary in advance that the item/service would not be covered by Medicare. Therefore, we have determined that the beneficiary did not know and could not reasonably have been expected to know that the item/service would not be covered.   Provider/Supplier model paragraphs for 1879 analysis    (Provider/supplier Option 1) In addition, we have determined that the (provider) (supplier) either knew or could reasonably be expected to know that the service/item would not be covered. [Explain the basis for determining that the provider/supplier knew or should have known the item/service would not be covered]   (Provider/supplier Option 2) We have determined that the (provider) (supplier) did not know and could not reasonably have been expected to know that the item/service would not be covered.   3. Include a summary paragraph to explain the liability of the parties to the appeal. Model summary paragraph for appeals where liability under 1879 is at issue    Since the (beneficiary) (provider) (supplier) has been determined to have had knowledge of the non- covered item/service, the (beneficiary) (provider) (supplier) is liable for the cost of the denied item/service. (The (provider or supplier) (may)(may not) bill the beneficiary for the cost of the denied item/service, and must refund any monies collected from the beneficiary.)   4. As noted above, the contractor shall (1) explain the basis for their determination of knowledge when making a determination of liability under 1879 of the Act, and (2) state who is responsible for the bill. For example, a regulation, a CMS or contractor publication, or specific policy posted on the contractors website, etc. may establish knowledge of non- coverage. See IOM 100 -04, Chapter 30, 40, et seq. for additional information. If the provider or supplier is held liable under 1879 of the Act for t he cost of the item/service, they may not collect from or bill the beneficiary for the cost of the item/service. The provider or supplier must refund any money collected for the item/service, including any coinsurance or deductible.  5. If neither the beneficiary, nor the provider or supplier knew or could reasonably have been expected to know that the item/service would not be covered, then Medicare makes payment for the item/service under 1879 of the Act.    6. If there is evidence to indicate that the beneficiary may have paid in advance for the items/services (e.g., the claim was billed with a GA modifier indicating an ABN was given to the beneficiary), or paid the applicable deductible or coinsurance amount s, and the provider/supplier is subsequently held liable under 1879 of the Act for the denied items/services, the contractor shall include a statement explaining the provider/suppliers obligation to refund any payments made by the beneficiary, including payment of any deductible or coinsurance. See 310.5.B. See also, 42 CFR 411.402; IOM 100- 04, Chapter 30, 30.1.2, 30.2.2, and 100, et seq. for information regarding indemnification procedures and IOM 100 -04, Chapter, 30, 10- 40 and 110- 150 for more inf ormation on liability protections and refund requirements.   7. If the basis for denial does not trigger the limitation on liability provisions of 1879 of the Act, the contractor explains the reason for the denial and includes the following, or similar language:   Since the item/service is (not a covered benefit under Medicare) (excluded from coverage under Medicare), we cannot make payment. The (provider) (supplier) may bill the beneficiary for the denied item/service.   8. Example of a complete financial responsibility section when a supplier is determined to be liable under 1879:   After determining that the item or service will not be covered by Medicare, we must determine who is financially liable for the denied item or service. When an item or service is denied under 1862(a)(1), 1862(a)(9), or 1879(g) of the Social Security Act (the Act), we must determine if the beneficiary and the provider or supplier either knew or could reasonably be expected to know that the item or service would not be covered. This is known as the limitation on liability provision of 1879 of the Act.   If the beneficiary was informed by their provider or supplier in writing in advance of receiving the item/service that Medicare may not make payment (through receipt of an Advance Beneficiary Notice of Noncoverage), the beneficiary may be responsible for t he cost of the denied item or service. If the provider or supplier knew or could reasonably be expected to know the item or service would not be covered, but the beneficiary did not have such knowledge, then the provider or supplier may be responsible for the cost of the denied item or service.   There is no evidence to indicate that the supplier notified the beneficiary in advance that the item/service would not be covered by Medicare. Therefore, we have determined that the beneficiary did not know and could not reasonably have been expected to know that the item/service would not be covered.   In addition, we have determined that the supplier either knew or could reasonably be expected to know that the service/item would not be covered by Medicare. Based on the coverage limitations explained in the contractors Local Coverage Determination (LCD) , L11518 (Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep   Apnea), the supplier knew or should have known the item provided would not be covered.   Since the supplier has been determined to have had knowledge of the non -covered item/service, the supplier is liable for the cost of the denied item/service. The supplier may not bill the beneficiary for the cost of the denied item/service, and must refund any monies collected from the beneficiary.>   WHAT TO INCLUDE IN YOUR REQUEST FOR A RECONSIDERATION OF THIS APPEAL   <Instructions: If the denial was based on insufficient documentation or if specific types of documentation are necessary to issue a favorable decision indicate what documentation would be necessary to pay the claim. Use option 1 if evidence is indicated in this section or option 2 if no further evidence is needed.>   Option 1:   <SPECIAL NOTE TO Medicare physicians, providers, and suppliers ONLY> Any additional evidence as indicated in this section should be submitted with the request for reconsideration. All evidence must be presented before the reconsideration decision is issued. If all additional evidence as indicated above and/or otherwise is not submitted prior to issuance of the reconsideration decision, you will not be able to submit any new evidence to the administrative law judge or the Medicare Appeals Council unless you can demonstrate good cause for withholding the evidence from the qualified independent contractor.   NOTE: You do not need to resubmit documentation that was submitted as part of the redetermination. This information will be forwarded to the QIC as part of the case file utilized in the reconsideration process.   Option 2:   <SPECIAL NOTE TO Medicare physicians, providers, and suppliers ONLY> Any additional evidence as indicated in this section should be submitted with the request for reconsideration. All evidence must be presented before the reconsideration decision  is issued. If all evidence is not submitted prior to the issuance of the reconsideration decision, you will not be able to submit any new evidence to the administrative law judge or the Medicare Appeals Council unless you can demonstrate good cause for wi thholding the evidence from the qualified independent contractor.   NOTE: You do not need to resubmit documentation that was submitted as part of the redetermination. This information will be forwarded to the QIC as part of the case file utilized in the reconsideration process.   Sincerely,     NAME, TITLE   CONTRACTOR NAME    IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS   Your Right to Appeal this Decision:  If you do not agree with this decision, you may file an appeal. An appeal is a review performed by people independent of those who have reviewed your claim so far. The next level of appeal is called reconsideration. A reconsideration is a new and impartia l review performed by a qualified independent contractor (QIC), separate and independent of (insert: contractor name).   How to Appeal: To exercise your right to an appeal, you must file a request in writing. Your request must be received by the QIC at the address below within 180 days of receiving this decision. You are presumed to have received this decision five days after the date of t he letter unless there is evidence to show otherwise. If you are unable to file your appeal request timely, please explain why you could not meet the filing deadline. You may request an appeal by using the form enclosed with this letter.  If you do not use this form, you can write a letter. You must include: your name, the name of the beneficiary, the Medicare number, a list of the service(s) or item(s) that you are appealing and the date(s) of service, and any evidence you wish to attach. You must also indicate that (insert: contractor name) made the redetermination. You may also attach supporting materials, such as those listed in item 10 of the enclosed Reconsideration Request Form, or other information that explains why this service should be paid. Your doctor may be able to provide supporting materials.  If you want to file an appeal, send your request to:    <QIC Name   Address   City, State Zip>   Who May File an Appeal:  You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.   If you want someone to act for you, you may visit http://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/downloads/cms1696.pdf to download the Appointment of Representative form, which may be used to appoint a representative. Medicare does not require that you use this form to appoint a representative. Alternately, you may submit a written statement containing the same information indicated on the form. If you are a