(Medicare Claims Processing Manual)

<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   Medicare beneficiary, you may also call 1 -800-MEDICARE (1 -800-633-4227) to learn more about how to name a representative.   Other Important Information: If you want copies of statutes, regulations, policies, and/or manual instructions CMS used to arrive at this decision, or if you have any questions specifically related to your appeal, please write to us at the following address <alternatively, if using th e same address at top of page one of letter, refer to that address rather than repeat the address here> and attach a copy of this letter:   Contractor Name,   A Medicare Contractor   Address   City, State Zip   Resources for Medicare Beneficiaries: If you want help with an appeal, or if you have questions about Medicare, you can have a friend or someone else help you with your appeal. You can also contact your State health insurance assistance program (SHIP). You can find the phone number for your SHIP in your Medicare & You handbook, under the Helpful Contacts section of www.medicare.gov website, or by calling 1- 800-MEDICARE (1 -800-633-4227). Your SHIP can answer questions about payment denials and appeals.  For general questions about Medicare, you can call 1- 800-MEDICARE (1 -800-633-4227), TTY/TDD: 1- 877-486-2048.   Remember that specific questions about your appeal should be directed to the contractor that is processing your appeal.                   Reconsideration Request Form   Directions: If you wish to appeal this decision, please fill out the required information below and mail this form to the address shown below.  At a minimum, you must complete/include information for items 1, 2a, 6, 7, 11, & 12, but to help us serve you better, please include a copy of the redetermination notice with your request.        1. Name of Beneficiary:  2a. Medicare Number:  2b. Claim Number (ICN / DCN, if available):  3. Provider Name:  4. Person Appealing:      Beneficiary   Provider of Service    Representative  5. Address of the Person Appealing:   5a. Telephone Number of the Person Appealing: ____________________________ 5b. Email Address of the Person Appealing: ________________________________ 6. Item or service you wish to appeal:  7. Date of the service: From    To     8. Does this appeal involve an overpayment?    Yes     No   *Please include a copy of the demand letter (if applicable) with your request.  9. Why do you disagree? Or what are your reasons for your appeal? (Attach additional pages, if necessary.)   10. You may also include any supporting material to assist your appeal. Examples of supporting materials include:   Medical Records    Office Records/Progress Notes   Copy of the Claim  Treatment Plan               Certificate of Medical Necessity  11. Name of Person Appealing:  12. Date:    Contractor Number  (Contractor number is optional for contractors with only one location for QICs to request case files)  (End) EXHIBIT 4 Contractor Logo or CMS Logo with Contractor Name and Address  Redetermination/ Appeals Number: XXXXXX  QIC Name  Address    310.8 - Medicare Redeter mination Notice (for Fully Favorable Redeter minations) (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  NOTE:  This activity  is NOT required until furt her noti ce, unl ess oth erwise specified in the MACs stat ement of work, except in those  situations whe n the  parties will not receive  notice of effectuation via  a MSN or RA (MSP over payments, non -MSP over payments whi ch do not re sult in a  refund o r payment, etc.).  MACs will a lso have to modi fy the language to ensure that the letter appropriately addresses the MSP over payment or non-overpayment situ ations.   The MAC  uses the redetermination f ormat below, (or som ething similar ) and st andard language paragraphs whether the redetermination notice is delivered via  hard copy mail or via a CMS-approved por tal/application.  The MAC  must e nsure that the information id entified in each s ection of  the mode l letter below is in cluded and addressed, as needed, in the  MRN.    (Start) EXHIBIT 5:       MONTH, DATE, YEAR   APPELLANT NAME                                              MEDICARE NUMBER OF  ADDRESS              BENEFICIARY:  CITY, STATE ZIP                                                        CONTACT INFORMATION:                 If you have questions, write or         call:               MAC Name                Address                City, State Zip                Telephone number   MEDICARE APPEAL DECISION   RE:   <Include claim identifier or appeal number>   Dear <Appellants Name>:   This letter is to inform you of the decision on your Medicare appeal.  This appeal decision is fully  favorable to you.  Our decision is that your claim is covered by Medicare.  More information on this decision, including the amount Medicare will pay, will follow in a future Remittance Advice or Medicare Summary Notice.   For information about filing a request for redetermination, please visit www.medicare.gov/appeals or http://www.cms.gov/OrgMedFFSAppeals/ .  Medicare beneficiaries may also contact your State health insurance assistance program (SHIP).  You can find the phone number for your SHIP in your Medicare & You handbook, under the Helpful Contacts section of www.medicare.gov Web site, or by calli ng 1- 800-MEDICARE (1 -800-633-4227).   Sincerely,    NAME, TITLE  Model Fully Favorable Redetermination Notice Coverage Decision     MAC NAME   (End) Exhibit 5    310.9 - Effect of the Redetermination  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  In accordance with s ection 1869(a)(3 )(D) of the Act, onc e a redetermination is issu ed, it becom es part of the initia l determination.  The  redetermination is binding upon a ll parties unl ess a reconside ration is c ompl eted or the redetermination is re vised as a result of  a reopening.  310.10  - System and Processing Requirements for Use of Secure Internet  Portal/Application to Support Appeals Activities  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  MACs who d evelop a nd utili ze a secure Internet portal/application f or appeals pur poses shall ensure , at a minim um:   CMS a pproves (i.e., contract ma nager or project o fficer, if applicable) the propos ed por tal/application a nd us age prior to de velopm ent and impl ementation.   The portal/application f ully complie s with a nd ha s been t ested to ensure complia nce with a ll CMS s ystem se curity requirements regarding protected health information pr ior to impl ementation/us age.   The secure Internet portal/application in cludes a formal registration p rocess that validates the identity of appellants using the portal.  This pr ocess sh all include, at a minimum, use  of restricted user identities a nd passwo rds.  A/B MACs (A), (B), (HHH), and DME MACs shall include an indi cation and/or  description of  the validation m ethodolog y in the  appeals case  file should a highe r level of appeal be submitte d.   Templates for submission of  electronic appeal requests sh all include, at a minimum, a me thod f or authenticating that the a ppellant ha s compl eted the  portal/application r egistration p rocess and has been properly identified by the system as an appropriate user.   All MACs utilizing an approved portal/application shall provide education to appellants regarding system capabilities/limitations prior to implementation and utilization of the secure portal/application.    MACs sh all also educate  appellants th at participation/enrollment in the  secure portal/application is a t the discretion of  the a ppellant and the  appellant be ars the responsibilit y for the authenticity of the in formation be ing a ttested to.   Appropriate procedu res are in pl ace to provide  appellants with c onfirmation of  receipt of the  appeal r equest via  secu re Internet/portal and verbiage instructing the appellant not to submit a dditiona l redetermination requests for the same item   or service via different v enue (hard copy mail or facsimile) .  This in formation is necessa ry to dis courage appellants from submitting multiple  appeal re quests for the same item/service through the  same or multiple venues (i.e., filed via  secure Internet portal/application a nd at a later date via mail).   MACs utilizing  a secure portal/application sh all ensure that there is a process in place by which an appellant can submit a dditiona l doc umentation/ma terials concurrent with the a ppeal request so as not to cause a delay in the  time ly processi ng of the a ppeal.  The po rtal/application sh all have the capability to accept a dditiona l doc umentation a nd/or  other materials to suppor t appeal requests.   Redetermination d ecisions and/or  dismissa l noti ces transmitte d via  a secure Internet portal/application sh all comp ly with the  time liness and content requirements as outlin ed in the IOM Pub. 100- 04, M edicare Claims P rocessing  Manual, chapter 29, unl ess othe rwise noted above .  In addition, MACs sha ll provide  hard copy decision a nd/or  dismissa l notices to p arties to the a ppeal who do not ha ve access to the  secure Internet portal/application.  T he notices must be mailed and/or  other wise transmitte d concurrently (i.e., mailed on the  same day the notice is transmitte d via  the secure portal/application ).   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)