evekhm/cms_iom_500 huggingface dataset:
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C. Exception  to S ending Decision  Letters to B eneficiaries in Overpayment Cases  In an over payment case involving multiple  beneficiaries who h ave no financial liability prior to, a nd following the redetermination, the  MAC  mails the  decision l etter to the  appellant or the ir appoint ed representative.  In this situ ation, MACs a re not re quired to s end the  decision l etters to be neficiaries who ar e parties to the  redetermination ( see 42 CFR 405.956(a)(2) ).  Howe ver, if financial liability shifts from the  provider or suppli er to the  beneficiary, the MAC  issues a separate decision l etter to the  beneficiary that explains w hy he/she is lia ble, and explains the  subs equent appeal r ights available.  Exampl e: During a post payment review, claims for multiple  beneficiaries are initially  denied as b eing not medically reasonable  and necessa ry, and the  determination of liability  unde r section 1879 of the  Act finds the physi cian finan cially responsible  for the  denied services.  I f during the appe al, the  physi cian demonstrat es that a valid ABN  was issu ed for some  of the  services pro vided to certain b eneficiaries and finan cial responsibility  shifts from the  physi cian to those be neficiaries, the  MAC must issue  separate decision l etters to the  affected beneficiaries, but is not r equired to issue  separate decision l etters to those  beneficiaries whose liability  has not c hange d (i.e., liability  remains w ith the  physi cian).   310 - Redetermination - The First Level of Appeal  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07 -23-13)
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310 - Redetermination - The First Level of Appeal  (Rev. 2729, Issued: 06 -21-13, Effective: 07 -23-13, Implementation: 07 -23-13)  A party dissatisfied with an initia l determination m ay request that the MAC  review its d etermination.  A redetermination is the  first level of appeal  after the initia l determination on P art A a nd Part B claims.  It is a second look a t the claim and suppor ting documentation a nd is m ade by an employee that did not ta ke part in the  initial d etermination.  I f an initia l determination is not m ade, ther e are no appeal rights on tha t claim (see 200.C  for a list of actions th at are not initi al determinations a nd the refore do not ha ve appeal rights).  The reviewer must c omply with, a nd is bound b y, all applicable  statutory and regulatory provisions.  The  reviewer may not ove rrule  the provisions of  the law or interpret them in a  way different than CMS; nor may the reviewer comm ent upon the  legality, constitution al or other wise, of any provision of  the Act, regulations, or CMS policy in the  review determination.  The  reviewer is also bou nd by all CMS-issued poli cies and procedures, including CMS rulings, Medicare manual instr uctions, c hange requests, n ational coverage determinations, a nd local c overage determinations.  The  reviewer must c onsider the applicabili ty of all CMS-issued poli cies and procedures to the  facts of  a given claim.  The  reviewer may not change the amount required to be  paid unde r the Physician Fee Schedule.    310.1 - Filing a Request for Redetermination  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)
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310.1 - Filing a Request for Redetermination  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  A request for redetermina tion must be  filed with the  contractor in w riting. The  request may be made by a party to the  appeal a s defined in 260 a nd/or  the partys representative as defined in 270. Appeal r equests submitte d electronically via a facsimile  or secure Internet por tal/application sh all be conside red to h ave been recei ved in w riting.  NOTE:  C ontracto rs are not re quired to utili ze a facsimile  and/or  a secure Internet po rtal/application f or performing a ppeals a ctivitie s.  Contracto rs may not require an appellant to file an appeal electronically (e.g., via facsimile  and/or  a secure Internet portal/application). Submission of  appeal re quests via  facsimile  or a portal/application sha ll be at the discretion of the  appellant.  C ontracto rs shall continue  to acc ept appeal requests in h ardcopy via mail.  A. W ritten Redetermination Requests Filed on Behalf of the Beneficiary  Someone othe r than an appoint ed representative may submit a  written request for redetermination on be half of a beneficiary. Persons who oft en act on be half of a b eneficiary in filing a r edetermination r equest include: the spous e, parent, child, sibling, ne ighbor or fri end. B eneficiary advocacy groups and Me mbers of C ongress may also submit a r equest for re determination on be half of a b eneficiary (see 310.1.A.1 for furthe r discussion on r equests submitte d by Members of Congress).
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The contractor honor s the request for redetermination if  the request clearly shows the  beneficiary knew of or approved the submission of  the request for redetermination (e .g., the request is submitte d with a  written author ization from the  beneficiary or with the  beneficiarys MS N). How ever, if the contractor has information th at the redetermination re quest was not submitt ed at the request of the beneficiary, the contractor  does not c onduc t the redetermination unl ess and/or until it receiv es confirmation from the  beneficiary that the request was submitte d with the be neficiarys approval.  If a redetermination r equest is submitte d by an indi vidual w ho is not the  beneficiarys appoint ed representative , all w ritten noti ces related to the  appeal are s ent only to the  beneficiary, not the indi vidual making the  request for re determination.  I n addition, if the  contra ctor honors a r equest for re determination filed by som eone othe r than the  beneficiary or the beneficiarys appoint ed representative , the contra ctor should c ontact the beneficiary (or an appoint ed/authoriz ed representative  if appli cable) if furth er information is needed to process the r edetermination.   NOTE: An authoriz ed representative  is an indi vidual authoriz ed unde r State or othe r appli cable law  to act on be half of a  beneficiary in an appe al, and has all of the  rights  and r esponsibilitie s of a b eneficiary with respect to the  appeal.  An authoriz ed representative  does not need to s ecure an appointm ent of r epresentative  from the  beneficiary in orde r to file  an app eal or obtain/r eceive information r elated to t he appeal.  S ee 270.1.1 f or additional informa tion regarding authoriz ed representative s.
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The person submitting the request does not a utom atically become  the representative until a nd unl ess an appointm ent of representative form or othe r written statement is c ompl eted (see 270 f or instructions on developing an inc ompl ete or absent appointm ent of representative).  There will be  circumst ances wh ere the mental and/or physical incapacity of the beneficiary becom es an issue. Based on all the  documented medical in formation a vailable, the contractor m ay decide  to allow the  person submitting  the request for redetermination t o act on be half of a beneficiary who is m entally or physically incapacitated. The  contractors decision, a s well as the b eneficiarys incapacita tion, should be  documented in the  file and suppor ted by relevant medical doc umentation.  1.  R equests for Redetermination Subm itted by Members of  Congress  When the  contractor  has honore d a request for redetermination f iled by a Member of Congress pu rsuant to a  Congre ssional inqui ry made on be half of a beneficiary or provider , physician or othe r suppli er, the contractor may continue  to provide the Member of Congress with st atus in formation on the  appeal a t issu e.  Status in formation inc ludes the progression of  the appeal th rough the  administra tive appeals process, including information on whe ther or when an appeal d etermination or  decision ha s been issu ed and wha t the decision w as (e.g., favorable, unfa vorable, partially favorable), but doe s not inc lude release of personal information a bout a be neficiary that the Member of Congress did not a lready have in his/h er possession. A beneficiary may want a Member of Congress to obt ain mo re detailed information a bout his/he r appeal without a ppointing the Member of Congress as a representative.  In this cas e, it would be necessa ry for the beneficiary to sign a release of information. The  contractor must accept  any of the  following as releases of information:
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 A signed copy of corresponde nce from the  beneficiary expressing a  desire for the c ongre ssion al office to obtain information on his/he r behalf;   A release of information form developed by the congression al office; or   A release of information form developed by the contractor  for this pu rpose.  If the Member of Congress expresses an interest i n acting a s the representative of a beneficiary or of a provider, physician, or other suppli er, the party must c ompl ete an appointm ent of re presentative form or written statement.  B. Wh at Constitutes a R equest for Redetermination  1. Wr itten Requests for Redetermination Made by Beneficiaries  Beneficiaries may request a redetermination by s ubmitting a c opy of th eir MSN, by filing a compl eted Form CMS-20027 or by submitting a l etter that indi cates dissatisfa ction w ith a c laim d etermination.  As not ed above , appeal r equests re ceived via  a facsimile  or secure Internet portal/application sha ll also be  consid ered recei ved in w riting.  Requests for redetermination m ay be submitte d in situ ations w here beneficiaries assume  that they will r eceive a re determination b y questioning  a payment de tail of the determination or  by sending additiona l information bac k with t he MSN, but don t actu ally say: I want a review.  For example, a written inqui ry stating, Why did you onl y pay $10.00?  is considered a  request for redetermination. C ommon examples of phrasing in letters from be neficiaries that constitute  requests for redetermination in clude, but ar e not limite d to the  follo wing:   Please reconside r my claim.   I am not s atisfied with t he amount pa id - please look a t it again.   My neighbor  got pa id for the same kind of  claim. My claim should be  paid too.
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 I am not s atisfied with t he amount pa id - please look a t it again.   My neighbor  got pa id for the same kind of  claim. My claim should be  paid too.   The request may contain the  word appeal or review.  Th ere may be instances in whi ch the  word review is used but w here the clear intent of the request is f or a status re port.  This should be c onsidered an inqui ry.  2.  Wr itten Requests for Redetermination Sub mitted by a S tate, Provider, Physician or O ther Supplie r  States, provider s, ph ysicians, or  othe r suppli ers with appeal r ights must submit w ritten requests via  mail, facsimile  or secure Internet portal/application ( if the  contractor choos es to r eceive requests via fac simile  or CMS approve d secure Internet portal/applic ation)  indicating  what they are appealin g and w hy. A redetermination r equest may be submitte d using:   a.   A  completed Form CMS-20027 c onstitu tes a request for re determination.  Compl eted means that all applic able spa ces are fille d out and all necessary  attachments are in cluded with the  request. The form c an be found o n the  CMS website at: http://www.c ms.gov/ cmsforms/do wnloads/ cms20027.pdf   b.   A  written request/letter.  At a minimum, the  request must c ontain the  following information:   1.  B eneficiary name; 2.  M edicare numbe r; 3.  The  specific service(s) and/or  item(s) for which the  redetermination is b eing re quested; 4.  The  specific date(s) of the service; and 5. The name of the party or the representative of the party.
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Frequently, a party will w rite to a contractor  concerning the initia l determination inst ead of  filing F orm CMS-20027. How  to ha ndle such letters depends upon the ir content and/or  wording.  A letter serves as a request for redetermination if  it contains the  information liste d above  and either: (1) explicitly asks the  contractor  to take further action, or  (2) indicates dissatisfaction with the c ontracto rs decision. T he contractor counts the  receipt a nd pr ocessing  of the letter as an appeal only if it treats it a s a request for redetermination.   NOTE :  The details of  its actions must be detailed (e .g., whe n action w as taken and wh at was don e) for possible  subs equent evidentiary and administra tive purposes.  c.   A secure Internet portal /appli cation. If a contractor has received CMS approval for the  use of a secure Internet portal/application to suppor t appeals a ctivitie s, appellants m ay (but are  not r equired to) submit re determination re quests via  the secure Internet portal/application. W ritten requests submit ted via  the portal/application sha ll include the required elements for a valid appeal r equest as outlined above  unde r 310.1.B.2.b.  NOTE: Some redetermination re quests m ay contain attachm ents.  F or example, if the RA is a ttache d to the  redetermination re quest that doe s not contain the  dates of service on the  cover and the  dates of service are highlighted or emphasized in some  manner on the  attached RA, this is a n acceptable redetermination request.  Where the required information is not listed on the request form but is provided within the documents or attachments submitted with the appeal, the request substantially complies with the requirements established in 42 CFR 405.944.  MACs shall not dismiss requests under 42 CFR 405.952(b)(2)  when redeterminations substantially comply with requirements.    3.  How  to Han dle Incomplete Requests for Redetermination:
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3.  How  to Han dle Incomplete Requests for Redetermination:  If any of the above  information refe renced in S ection 2 is not inc luded with an a ppeal r equest submitte d by a party  or th eir representative  (other than a b eneficiary, or a be neficiarys representative ), the request is conside red inc ompl ete and the  contractor  issues a dismissal notic e with a n explanation of  the information that must be  included (see 310.6 f or more information on dismiss als).  Contra ctors should not c onside r beneficiary requests as in compl ete, whether filed by the  beneficiary or by their representative .  Contra ctors must c ontact beneficiaries (or their representative s), when necessary, to obtain missing information neede d to process the r edetermination.   4.  How  to Han dle Multiple Requests for Redetermination for the Same Item/Service:  a. Duplicate requests (multiple  requests from same part y) while an appeal is p ending.  If an app eal for an it em or s ervice is pending and the  appellant submits a duplic ate request for re determination, the  contractor combine s the requests into one  redetermin ation.  T he contra ctor shall in clude verbiage  indicating that dupli cate requests for re determination had been r eceived (on w hat dat es and via what venues, if multiple  venues were utiliz ed).  Adjudi cation time  fram es are still bas ed on the  first request for re determin ation.  N OTE: See 310.4.D.4 for ex tending adjudi cation time fram es if additional information  is submitte d with the  second appe al request.   If the contra ctor id entifie s a patt ern in w hich an app ellant or groups of app ellants are  repeatedly submitting dupli cate requests for re determination, the  contra ctor shall ta ke additional st eps to e ducate the appellant r egarding the  appeals pro cess.
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b. M ultiple  requests from different parti es while an appeal is p ending.  If an app eal for an it em or service is pending and anothe r party  to the  redetermination submits a r equest for re determination, the  contractor shall c ombine  the redetermination r equests and issue  a decision w ithin 60 da ys of the  latest filed request, in a ccordan ce with 42 C FR 405.944( c).   When issuing the  decisi on or dismissal noti ce, the  contra ctor shall in clude verbiage  indicating that requests for re determination had been r eceived from multiple  parti es (on w hat dat es and via w hat venues, if multiple  venues were utiliz ed) so that it is c lear to the  parti es that the  decision or dismissal was issu ed timely in accordan ce with 42 C FR 405.950( b)(2).  c. Duplicate or m ultiple  requests wh en an appeal is complete.  If a decision or dismissal notic e has been issu ed (including an M SN or RA for a fu lly favorable  decisio n), and the  contra ctor recei ves an additional r equest for re determination for that ite m/service (a duplicate request from the  appellant or a subsequent request from a diffe rent part y), the contra ctor shall tr eat the additional r equest as an inquir y.  The contra ctor dir ects the  party  to file  a request for reconside ration w ith the  appropriate  QIC.  d. Workload - Whenever the contra ctor combine s duplicate or multiple  requests for re determination as explained above , the contra ctor shall e nsure  that the  workload r eporting r eflects one  redetermination receipt and one  redetermination c ompl eted.
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NOT E:  If a party  files a request for reco nsideration  with the  contra ctor after a redetermination d ecision or dismissal no tice has b een issu ed, the  contra ctor tr eats the  reconside ration r equest as misfile d and f orwards the request to the  QIC for a r econside ration in a ccordan ce with 320.1.B.   Contracto rs shall not issue a dismiss al noti ce in response  to a dupli cate request or multiple r equests for redetermina tion.  NOTE: In accordance with IOM 100- 04, c hapter 29, s ection 310.6.3, if  an appellant requests th at the contractor vacate its dismiss al action, or  an app ellant ref iles a corrected appeal in re spons e to a dismiss al, and the  contractor  determines that it cannot vacat e the dismiss al, then it s ends a l etter notifying the appellant accordingly.  If evidence or information not previously submitted with the redetermination request is submitted with the request to vacate the dismissal, the letter must specifically address that new evidence or information.  T he contractor shall not issue  a second dismiss al noti ce to the  appellant.  5.  L etters a nd Calls Th at Are Considered  Inquiries  See IOM 100-09, M edicare Contractor  Beneficiary and Provide r Communi cations M anual. The c ontractor consider s the letter or telephon e call a n inqui ry (i.e., not  an appeal request) if:
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 It is c learly limite d to a  request for an explanation of  how M edicare calculated pa yment.  (For example, if a ph ysician sends a l etter inquiring about the  payment rate for a parti cular ite m or service, but it is not in c onnection w ith a c laim that has  been proces sed for the  item or s ervice, the letter is tr eated as an inqui ry.  Ho wever, if the  phys ician que stions the amount paid for an item or s ervice on a  claim that w as pro cesse d to pa yment, and ass erts additional pa yment is warrant ed, the  contra ctor handl es this as an app eal of the  payment amount, even if the  item/service was paid unde r a fee schedule.  See 200. C.3);   The party  is only as king for the  status on a  previous ly submitte d appeal r equest or correspond ence.  The contractor  states in its reply that is re sponding to a status re quest.  It does not use  the word review in its re ply;   It is a  request for information;   It is a r equest for re determination, made  by a party  othe r than the  appellant, for the  same item/service for which a d ecision or dismissal noti ce has alr eady been issu ed.  In responding to the inquir y, the  contra ctor shall inf orm the  party  making the  request that a d ecision has b een issued and the  party  should file  a reconside ration w ith th e appropriate Q IC.  Contra ctors shall  not issue  a dismissal noti ce.
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 It is a r equest for re determination, submitte d by an indi vidual ( who is not an appoint ed or authoriz ed representative ), filed on behalf of a pro vider, physi cian, suppli er, or othe r non-beneficiary party, and the  request doe s not inc lude an appointm ent instrum ent (see 270.1.6.B.2) .  The contractor follo ws the procedur es in 270.1.6.B.2.   The party asks onl y for a second c opy of a notice.  NOTE:   If the contractor  receives a request for reconside ration  (assuming the appellant is using the wrong form or incorrect terminolo gy), but de termines that a redetermination ha s not b een c onduc ted, the  contractor  does not f orward the  request to the  QIC.  The contractor sh all conside r the request as a redetermination r equest.   If the contractor receives a request for reconsideration from a party, or a 'request for reconsideration' that was mistakenly directed to them by another contractor, and the contractor has already conducted a redetermination, the contractor shall forward the request  to the  appropriate QIC, along with the  case  file within 60 cal endar days of receipt in the  corporate mailroom. Refer to 320.1.  Parties to a  claim must f ile a request for redetermination with the  proper contractor  based on the c laims processi ng jurisdiction r ules establish ed by the Medicare program.  Jurisdiction is establish ed based on either the State where the service was provided (for  Part B claims n ot involving DME ), the State where the beneficiary resides (for  Part B DME  claims on ly), or the lo cation of  the A/B MAC (for Part A p rovide r claims).  There may be inst ances wh ere requests for redetermination a re directed to the  wrong contractor.  Contractors shall have standard operational procedur es, inc luding maintaining a record of these cases, in place to ensure that misfiled  requests are forwarded to the  proper contractor jurisdiction within 60 ca lendar days of receipt.
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Refer to  310.4.A for information on determining whether misfiled requests for appeal are processed in a timely manner.   310.2 - Time Limit for Filing a Request for Redetermination  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A party must f ile a redetermination re quest within 120 da ys of the date of receipt of  the notice of initi al determination ( MSN or RA) with the  contractor indicated on the  notice of initia l determination (receipt of the notice of initial d etermination is pr esumed to be  5 da ys aft er the date of the  MSN or RA unl ess there is evidence to the contrar y).  The  date of filing for requests filed in w riting is defined as the date received by the appropriate contractor  in the  corporate mailroom, the  date received via  facsimile , or the date received in the secure Internet por tal/application, as evidenced by the receiving offices date stamp on the request.  I f the party has filed the  request in p erson with the  contractor, the filing date is the  date of filing at such office, as evidenced by the receiving offices date stamp on the  request.  If the party has mailed or filed in person the request for redetermination to a C MS, SSA, R RB office, or anothe r contractor  or Gov ernment agency within the  time  limit, a nd the  request did not reach the a ppropriate contractor until after the time  period to file a request expired, the  contractor  shall consider the date the request was first filed with a contractor or an official Federal government entity as the date of receipt for purposes of determining if the redetermination request was filed in a timely manner .