(Medicare Claims Processing Manual)

De Novo -  Latin phrase meaning anew or afresh, used to denote the manner in which claims are adjudicated in the administrative appeals process.  Adjudicators at each level of appeal make a new, independent and thorough evaluation of the claim(s) at issue, and are not bound by the findings and decision made by an adjudicator in a prior determination or decision.    Decisions and Determinations - If a Medicare appeal request does not result in a dismissal, adjudication of the appeal results in either a determination or decision.  There is no apparent practical distinction between these two terms although applicable regulations use the terms in distinct contexts.    A decision that is reopened and thereafter revised is called a revised determination.    Dismissal -  An action taken by an adjudicator when an appeal will not be conducted as requested.  A request for appeal may be dismissed for any number of reasons, including:    1. Abandonment of the appeal by the appellant;  2. A request is made by the appellant to withdraw the appeal;  3. A determination that an appellant is not a proper party;  4. The amount in controversy requirements have not been met; and  5. The appellant has died and no one else is prejudiced by the claims determination.    Limitation on Liability Determination - Section 1879 of the Social Security Act (the Act) provides financial relief to beneficiaries, providers and suppliers by permitting Medicare payment to be made, or requiring refunds to be made, for certain services and items for which Medicare coverage and payment would otherwise be denied. This section of the Act is referred to as the limitation on liability provision. Both the underlying coverage determination and the limitation on liability determination may be challenged. For more detailed information see chapter 3 0 of this manual.     Medicare number and/or  Medicare beneficiary identifier (Mbi)  - are general terms describing a beneficiarys Medicare identification number.  Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition p eriod and after for certain business areas that will continue to use the HICN as part of their processes.  For the beneficiary population, the term Medicare number is used to describe the Medicar e beneficiary identifier (Mbi).     Office of Medicare Hearings and Appeals (OMHA) -  The Office of Medicare Hearings and Appeals is responsible for level 3 of the Medicare claims appeal process and certain Medicare entitlement appeals and Part B premium appeals.  At level 3 of the appeals process, an appellant may have a hearing before an OMHA ALJ, or review by an attorney adjudicator.    Party -  A person and/or entity normally understood to have standing to appeal an initial determination and/or a subsequent administrative appeal determination or decision. (See section 210 in this chapter.)    Provider of services (herein provider)  As used in this section, the definition in 42 CFR 405.902 for provider applies.  Provider means a hospital, a critical access hospital (CAH), a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicar e, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization or intensive outpatient  services.  NOTE: A non- participating provider, that is, an entity eligible to enter into a provider agreement to participate in Medicare but has not entered into such an agreement, is not considered a provider of services and does not have party status for  an initial determination or appeal.    Qualified Independent Contractor (QIC)   Entity that contracts with the Secretary in accordance with the Act to perform level 2 appeals, which are called reconsiderations, and expedited reconsiderations.    Remand  An action taken by an adjudicator to vacate a lower level appeal decision, or a portion of the decision, and return the case, or a portion of the case, to that level for a new decision.    Reopening -  See IOM 100 -04 Chapter 34.    Reversal -  Although appeals in the administrative appeals process  are de novo proceedings (i.e., a new determination/decision is made at each level), Medicare uses this term where the new determination/decision is more favorable to the appellant than the prior determination/decision, even if some aspects of the prior det ermination/decision remain the same.    NOTE: The term reversal describes the coverage determination, not the liability determination. For  example, an item or service may be determined to be non -covered as not medically reasonable and necessary (under section 1862(a)(1)(A) o f the Act), but Medicare may, nevertheless, make payment for the item or service if the party is found not financially liable after applying the limitation on liability provision (section 1879 of the Act).  Thus, the coverage determination is affirmed, but Medicare makes payment as required by statute.    Revised Determination or Decision -  An initial determination or decision that is reopened and which results in the issuance of a revised determination or decision.  A revised determination or decision is considered a separate and distinct determination or decision and may be appealed. For example, a postpayment review of an initial determination that results in a reversal of a previously covered/paid claim (and, potentially, a subsequent overpayment determination) constitutes a reopening and a revised initial determination.  The first level of appeal following a revised initial determination is a redetermination. Spouse - The word spouse as used in this chapter, and as used in sections 405.952, 405.972, 405.1052, and 405.1114 of title 42 of the Code of Federal Regulations (CFR) regarding the dismissal of an appeal includes same- sex spouses as well as opposite -sex spouses.  The relationship of two individuals of the same sex will be recognized as a marriage if either (1) the sta te or territory in which the individuals live recognizes their relationship as a marriage, or (2) the individuals entered into a legally valid marriage under the law of any state, territory, or foreign jurisdiction.  Because civil unions and domestic partnerships are not marriages, civil union and domestic partners are not regarded as spouses by CMS.    Supplier Unless the context otherwise requires, a physician or other practitioner, a facility, or entity (other than a provider of services) that furnishes items or services under Medicare.    Vacate  To set aside a previous action.   200 - CMS Decisions Subject to the Administrative Appeals Process  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)     A. Entitlement Determinations    In accordance with a memorandum of understanding with the Secretary, the Social Security Administration (SSA) makes initial Part A and Part B entitlement determinations and initial determinations on applications for entitlement.  Individuals should contact the SSA for administrative appeals involving entitlement (telephone 1- 800-772-1213 (TTY 1- 800-325-0778 or access the SSAs website at:  http://ssa.gov/pgm/medicare.htm ).  This would include issues that involve the question of whether the beneficiary:     Has attained age 65 or is entitled to Medicare benefits under the disability or renal disease provisions of the law;     Is entitled to a monthly retirement, survivor, or disability benefit;     Is qualified as a railroad beneficiary;     Met the deemed insured provisions; and     Met the eligibility requirements for enrollment under the supplementary medical insurance (SMI) program or for hospital insurance (HI) obtained by premium payment.    If a beneficiary is dissatisfied with the SSAs initial determination on entitlement, he or she may request a reconsideration with the SSA.  The SSA performs a reconsideration of its initial determination in accordance with 20 CFR part 404, subpart J .  Following the reconsideration, the beneficiary may request a hearing before a HHS Administrative Law Judge (ALJ).  If the beneficiary obtains a hearing before an ALJ and is dissatisfied with the decision of the ALJ, he or she may request the Appeals Council to review the case.  Following the action of the Appeals Council, the beneficiary may be entitled to file suit in Federal district court.    B.  Initial Determinations     The Medicare contractor makes initial determinations regarding claims for benefits under Medicare Part A and Part B.  A finding that a request for payment does not meet the requirements for a Medicare claim shall not be considered an initial determination.  An initial determination for purposes of this chapter includes, but is not limited to, determinations with respect to:    (1) Whether the items and/or services furnished are covered under title XVIII of the Act;    (2) In the case of determinations on the basis of section 1879(b) or (c)  of the Act, whether the beneficiary, or supplier who accepts assignment under 42 CFR 424.55 knew, or could reasonably have been expected to know at the time the services were furnished, that the services were not covered;    (3) In the case of determinations on the basis of section 1842(l)(1)  of the Act, whether the beneficiary or supplier knew, or could reasonably have been expected to know at the time the services were furnished, that the services were not covered;    (4) Whether the deductible has been met;    (5) The computation of the coinsurance amount;    (6) The number of days used for inpatient hospital, psychiatric hospital, or post -hospital extended care;    (7) Periods of hospice care used;    (8) Requirements for certification and plan of treatment for physician services, durable medical equipment, therapies, inpatient hospitalization, skilled nursing care, home health, hospice, partial hospitalization services , and intensive outpatient services ;    (9) The beginning and ending of a spell of illness, including a determination made under the presumptions established under 42 CFR 409.60(c)(2) , and as specified in 42 CFR  409.60(c)(4) ;    (10) The medical necessity of services, or the reasonableness or appropriateness of placement of an individual at an acute level of patient care made by the Quality Improvement Organization (QIO) on behalf of the contractor in accordance with 42 CFR 476.86(c)(1) ;    (11) Any other issues having a present or potential effect on the amount of benefits to be paid under Part A or Part B of Medicare, including a determination as to whether there has been an underpayment of benefits paid under Part A or Part B, and if so, the am ount thereof;    (12) If a waiver of adjustment or recovery under sections 1870(b) and (c)  of the Act is appropriate :    (i) when an overpayment of hospital insurance benefits or supplementary medical insurance benefits (including a payment under section 1814(e)  of the Act) has been made with respect to an individual, or    (ii) with respect to a Medicare Secondary Payer recovery claim against a beneficiary or against a provider or supplier ;    (13) Whether a particular claim is not payable by Medicare based upon the application of the Medicare Secondary Payer provisions of section 1862(b)  of the Act;    (14) Under the Medicare Secondary Payer provisions of section 1862(b)  of the Act that Medicare has a recovery claim against a provider, supplier, or beneficiary for services or items that have already been paid by the Medicare program, except when the Medicare Secondary Payer recovery claim against the provider or supplier is  based upon failure to file a proper claim as defined in 42 CFR part 411 because this action is a reopening;     (15) A claim not payable to a beneficiary for the services of a physician who has opted- out. NOTE: A physician who has opted- out of Medicare is not considered a party to the initial determination or any subsequent appeal; and      (16) Under the Medicare Secondary Payer provisions of section 1862(b)  of the Act that Medicare has a recovery claim if Medicare is pursuing recovery directly from an applicable plan. That is, there is an initial determination with respect to the amount and existence of the recovery claim.    C.  Actions That Are Not Initial Determinations    Actions that are not initial determinations and are not appealable under this chapter include, but are not limited to     (1) Any determination for which CMS has sole responsibility, for example: whether an entity meets the conditions for participation in the program; whether an independent laboratory meets the conditions  for coverage of services; or a determination under the Medicare Secondary Payer provisions of section 1862(b)  of the Act of the debtor for a particular recovery claim;     (2) The coinsurance amounts prescribed by regulation for outpatient services under the prospective payment system;    (3) Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a contractor has sole responsibility under Part B, such as the establishment of a fee schedule set forth in 42 CFR, part 414, subpart B , or an inherent reasonableness adjustment pursuant to 42 CFR  405.502(g)  and any issue regarding the cost report settlement process under Part A: