evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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.
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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.
(Medicare Claims Processing Manual)
 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).
(Medicare Claims Processing Manual)
 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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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
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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
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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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.   (b) Phone  Requests - MACs sh all designate and m aintain a phone  extension speci fically for the receipt of case  file requests fro m the  QIC.  MACs  shall designate a main contact p erson and ba ck-up contact th at is a vailable to take phone  calls du ring core busine ss hour s on a ll busin ess days (unless oth erwise agreed upon in the  JOAs).  (c) Fax Requests - MACs sh all designate and m aintain a fax machine  for the receipt of  case  file requests fr om the QIC.
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(c) Fax Requests - MACs sh all designate and m aintain a fax machine  for the receipt of  case  file requests fr om the QIC.   320.5 - QIC Case File Preparation  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Once a party requests a reconside ration with a  QIC, the QIC will n eed to o btain the  case  file from the  MAC that issu ed the  redeterminatio n decision.  The  founda tion for an effective, efficient and accurate appeals s ystem is the  case  file.  It is e ssential that the case  file contain all relevant information a nd evidence concerning an appeal in an organiz ed manner so th at the QIC can m ake a correct and fair determination.  The  MAC  prepares the case file by s eparating procedural doc uments   and medical do cuments and builds the  case  file from the  bottom up, with the  olde st set of documents on the  bottom, a nd the  most recent s et of documents at the top.  How ever, it doe s not pl ace the medical doc umentation on the  bottom.  M edical do cumentation doe s not nee d to be  ordered chronologically, but r ather can be included in t he case  file as submitte d by the provide r.  For large  cases containing multiple  beneficiary files, the  MAC shall organize  the case fil es by individual be neficiary files in alphabe tical order.  A packing list w ill be included for m ultiple beneficiary box c ases and lab eled as box n umber x of  y.
(Medicare Claims Processing Manual)
As the MACs begin utilizing the MAS for processing redeterminations (timeframe by jurisdiction TBD), the MACs shall work to update their JOAs with QICs to include language indicating that the appeals case file will be obtained via electronic promotion of t he level one appeal record within the MAS.  The MAC QIC JOAs shall include language to address situations in which the MAS is down or otherwise unavailable for short term and/or long term periods of time.  In addition, the JOA shall include language to address processes and procedures for providing case files that are not in the MAS due to the redetermination having been processed prior to the level one MAS implementation and/or the rare instance that the file is otherwise not available in the MAS.   For one  QIC case add ressing multiple  beneficiaries, parti cularly  large multi- beneficiary and overpayment cases, the  MAC shall keep the  documents relating to e ach beneficiary toge ther and organiz ed alphabe tically by be neficiary last nam e.  Documents relating to e ach beneficiary will be  separat ed and a c omplete set of pro cedural doc uments w ill be  provided for e ach beneficiary.  The following is a list of  the documents ge nerally included in a ny case file.  Note  that there may be other s not liste d here .  For applicable items, the  MAC i ncludes originals and re tains ha rd copies of any documents th at are not a vailable electronically for its reco rds.  Do not s end abbreviated versions, or versions of  documents that the MAC  has retyped or paraphrased for pur poses of shor tening the document.  The  MAC must k eep a n exact copy of the file that is sent to the  QIC.  (Note:  This applies onl y when documents ar e not othe rwise available e lectronically.)  If it is un able to include the original doc uments, it in cludes photoc opies that are true facsimile s of the original doc uments.  It arranges the following documents, in de scendi ng date order (i.e., the  claim form is on the  bottom ). Procedur al Do cuments:
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 Claim form or printout, if  electronically generated (fac simile  and/or  screen prints are acceptable);   MSN/RA - olde r files may contain EOM Bs or Denial Letters, whi ch must a lso be included.  (Facsimile  and/or screen prints a re acceptable);   Redetermination re quest;   Redetermination noti ce;   Appointm ent of representative form (F orm CMS-1696)  or othe r written author ization, if  applicable;     All do cumentation re lated to the  assessment of an over payment.  Med ical Do cuments:   Medical records, separated by facilit y, doc tor, or location of  service (separated by a colore d she et or a sheet of paper with a  headi ng);   Referral to/from MAC  medical st aff (with p rofession al qua lifications o f the reviewer noted in the  document, if  applicable)   MAC  medical poli cies and opinions re levant to claim(s).  (In addition to MAC medical poli cy, the MAC  should inc lude in the case  file any information it h as as back ground to the  particular policy at issu e.  For example, finding s of the MAC  advisor y committe e (CAC) with re gard to the  policy, including profession al publi cations re lied upon to suppor t the policy, opin ions from pr ofession al medical societies who m ay have comm ented on the  policy during the developm ent ph ase, etc.)  (See the Program Integrity Manual, Pub. 100- 08 for addition al information.) ;*   A list of  relevant por tions of  the law, regulations, C MS rulings, national coverage determinations/d ecisions, a nd C MS manuals;   Copies of LCDs, n ewsletters, any other pertinent information th at may be used by the QIC;*   Any other exhibits th at the MAC m ay conside r impo rtant for the QIC to conside r (e.g., certification of  reasonable charge, fee schedule information, noti ces of nonc overage, MAC publi cations.) ; and