evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
340.3 - Requests for Case Files         (Rev. 4278, Issued: 04 -12-19, Effective: 06- 13-19, Implementation: 06- 13-19)          When the Appeals Council receives a request for review from an appellant, in most          instances it will not have a copy of OMHAs decision or dismissal, or the case file.  The Appeals Council will request all case files from the AdQIC.   340.4 - Payment of Interest on Appeals Council Decisions  (Rev. 985, Issued:  06- 16-06; Effective/Implementation Dates:  07 -17-06)  For guidance on how to make payment of interest subsequent to an Appeals Council decision, refer to chapter 3, of the Medicare Financial Management Manual, Pub. 100- 06.    345 - U.S. District Court Review - The Fifth Level of Appeal  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The circumst ances a llowing for an appeal or  escalation to the  U.S. Dist rict Court level of review are limite d, and ar ticulated in 42 C FR 405.1136.  345.1 - Requests for U.S. District Court Review by a Party  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
345.1 - Requests for U.S. District Court Review by a Party  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Following issuance of a decision b y the App eals Counc il, a party may request judi cial re view of the  App eals C ounc ils decision.  A MAC  cann ot accept r equests for judicial re view.  The appellant must f ile the compl aint with the  U.S. District Court.  See 42 C FR 405.1136.  If a party files a request for judicial review with a  MAC, the  MAC  must imm ediately notify the appellant that the  complaint must be  filed with th e appropriate  U.S. Dist rict Court (i.e., the distric t court for the  judicial distric t in w hich the  party  resides or w here such indi vidual, institution, or age ncy has its prin cipal pla ce of bus iness).  However, t he appellant is r esponsible for d etermining w here the complaint must be  filed.  MACs shall not f orward the  complaint to a distric t court as a c ourtesy to the  appellant.   The amount re maining in controversy must meet the required threshold.  C urrent amount in controve rsy threshold figure  available  on the  CMS website  at: http://www.c ms.gov/ Medicare/App eals-and-Grievances/Org MedFFSApp eals/Review-Federal- Distric t-Court.html .  See 250.    If a MAC  receives a copy of a summons or  complaint for judi cial review in federal distric t court, a nd it doe s not a ppear  that a copy was sent to the  following address, the MAC  shall send the original to:  Department of Health a nd Hum an Services General Couns el 200 Independence Avenue, S.W. Washing ton, D.C . 20201
(Medicare Claims Processing Manual)
Department of Health a nd Hum an Services General Couns el 200 Independence Avenue, S.W. Washing ton, D.C . 20201   The MAC  retains a copy and noti fies its C ontra cting Offi cers Representative  (COR) immediately.  T he CMS COR should al ert the CMS Central Office C ouns el that a c omplaint has b een for warded by the  MAC to the HHS  General C ouns els offi ce.  345.2 - Effectuation of U.S. District Court Decisions  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The U.S. Dist rict Court may remand the  case  to the App eals C ounc il or ALJ for further proceedi ngs.  In rare cases, the  U.S. Dist rict Court will issue  an order that will require effectuation b y a MAC.  In this situ ation, the  MAC  immediately contacts its C ontra cting Officers Representative /Contra ctor M anag er for further instructions bef ore taking a ny action.  345.3 - Payment of Interest of U.S. District Court Decisions (Rev. 862, Issued: 02- 17-06, Effective: 05 -01-05, Implementation: 03- 17-06)  For guidance on how to make payment of interest subsequent to a U.S. District Court decision, refer to chapter 3 of the Medicare Financial Management Manual, Pub. 100 -06.  350 - Workload Data Analysis  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Data analysis involves collecting relevant data, analyzing the data, identifying trends and aberrancies, and making conclusions based on the data collected.  Data analysis should be performed, as needed, at all relevant operational sites to identify ineffi ciencies or problems with appeals.  Within the constraints of the current operating environment, MACs should work to address and resolve concerns.  Significant issues should be raised to CMS, preferably through the COR or Contract Manager.
(Medicare Claims Processing Manual)
360 - Managing Appeals Workloads  (Rev. 675, Issued: 09- 16-05, Effective: 10 -01-05, Implementation: 10- 03-05)  360.1 - Standard Operating Procedures  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The priorities set forth in this s ection ar e to be  used by MACs  as a guide in establishing standard ope rating procedures for managing an appeals wo rkload when the  budg et amount is   insuffi cient to a dequately perform the  required functions.  In general, MACs should use  a first-in, first-out m ethod to pr ocess a ppeals a nd m anage workload; how ever, during times of limite d resources it ma y become  necessa ry to prioritize the processing  of appeals to mo re efficiently manage the workload.  W hile CMS continue s to recomm end the priorities liste d in this s ection, there may be instances wh ere MACs f ind it mo re effective  and eff icient to pr ioritize in a different manner.  Also, MACs  may choose  to establish s tandard ope rating procedur es for managing an appeals wo rkload tha t deviate from the priorities listed in this s ection.  In both these cases, MACs should submit a  copy of their prioritization pl an to the Contra cting Offi cers Representative /Contra ctor M anag er and obt ain written approval for this v ariation within 30 days of the  start of  the fiscal year or period of pe rform ance.  360.2 - Execution of Workload Prioritization  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
360.2 - Execution of Workload Prioritization  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Budget Related Workload Prioritization  Whenever it appears that the budget amount is insufficient to adequately perform the required functions and the need for additional funds can be adequately documented, MACs shall submit a Supplemental Budget Request (SBR) in accordance with the IOM Pub. 10 0-06 Medicare Financial Management Manual, chapter 2 120.  As a result of an SBR, or during the course of CMS' evaluation of an SBR, CMS may find it necessary that the MAC execute prioritization of workload in accordance with this section or in accordance  with the MACs standard operating procedures.  The MAC should discuss possible alternatives for resolution in the SBR.  If it becomes necessary to abate activities, MACs must submit proper notification in accordance with the terms of the Cost of Administr ation Article in the Contract/Agreement and begin processing work in accordance with this PM until a final agreement is reached between the MAC and CMS.  As a result of an abatement, CMS may find it necessary that the MAC continue processing work in accordance with this manual instruction.   B. Other Circumstances That May Lead to Workload Prioritization   In circumstances other than those described above, it may become apparent that prioritization of workload is necessary because a MAC is unable to complete the incoming or pending workload within the time frames described in this manual.  In these situation s the MAC must either consult with the COR immediately for guidance or notify the COR that they plan to initiate their workload prioritization plan.  An example of a situation that may lead to workload prioritization is an uncharacteristic, unanticipated i ncrease in receipts over a two -month period, coupled with, insufficient staff or other resources that will impede you from completing the increased volume of appeals receipts in a timely manner.        360.3 - Workload Priorities  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
360.3 - Workload Priorities  (Rev. 4278 , Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Priority 1 - Finalize effectuation of all redetermination, reconsideration, ALJ and Appeals Council decisions and process redeterminations and forward reconsideration case files to the QIC timely on overpayment determinations (including CERT contractor appeals).  Priority 2 - Prepare, assemble, and forward case files to the QIC in accordance with the timeframes described in 320.6  Priority 3 - Adjudicate redeterminations from beneficiaries or their appointed beneficiary representatives in the timeframes described in 310.4.  Priority 4 - Adjudicate requests for redeterminations from providers, suppliers, or other appellants, including States or their third party agents, that are submitted with necessary documentation in the timeframes prescribed in 310.4.  Priority 5 - Adjudicate written requests for redeterminations from providers, suppliers, or other appellants, including States or their third party agents, that are submitted without  necessary documentation in the timeframes prescribed in 310.4.
(Medicare Claims Processing Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 01/04/2024  13222  R4380CP  08/30/2019  Pub. 100- 04, Chapter 29  Appeals Signature Requirement Changes  10/01/2019  11352 R4278CP  04/12/2019  Pub. 100- 04, Chapter 29  Appeals of Claims Decisions -  Revisions  06/13/2019  11042 R3549CP  06/24/2016  Pub. 100- 04, Chapter 29  Appeals of Claims Decisions Update: Revisions to Timeliness Requirements for Forwarding Misfiled Appeal Requests, Reconsideration Request Form, and Guidelines for Writing Appeals Correspondence  07/26/2016  9600 R2926CP  04/11/2014  Chapter 29 Appeals Update (Includes Post -DOMA Guidance and Signature Requirement for Appointment of Representatives and Assignment of Appeal Rights)  07/14/2014  8588 R2729CP  06/21/2013  Appeals Revisions -Final Regulation  07/23/2013  7840 R1986CP  06/11/2010  Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Appeals Via Facsimile and/or Via a Secure Internet Portal/Application  10/01/2010  6958 R1965CP  05/07/2010  Appeals Revisions -AIC Requirements  08/09/2010  6894 R1878CP  12/18/2009  Revisions in Timeliness Requirements for Forwarding Misfiled Appeal Requests  01/19/2010  6701 R1762CP  07/02/2009  Appeals Revisions  08/03/2009  6377
(Medicare Claims Processing Manual)
Rev #  Issue Date  Subject  Impl Date  CR#  R1688CP  02/20/2009  Clarification of the Medicare Redetermination Notice for Partly or Fully Unfavorable Redetermination 03/20/2009  6302 R1676CP  01/30/2009  Change in the Amount in Controversy Requirement for Administrative Law Judge Hearings and Federal District Court Appeals  05/04/2009  6295 R1485CP  03/28/2008  Chapter 29 Clean -Up 07/07/2008  5899 R1457CP  02/22/2008  Redeterminations of Overpayments  03/24/2008  5859 R1437CP  02/05/2008  Change in the Amount in Controversy Requirement for Administrative Law Judge Hearings and Federal District Court Appeals  05/05/2008  5897 R1408CP  01/11/2008  Modification to the Model Medicare Redetermination Notice (for partly or fully unfavorable redeterminations)  02/11/2008  5836 R1329CP  08/31/2007  Modifications to the Timeliness Requirements for Contractors Forwarding Reconsideration Requests Submitted to the Wrong Contractor  10/01/2007  5602 R1276CP  06/29/2007  Waiving Medicare Fee -for-Service Appeals Requirements  07/30/2007  5322 R1274CP  06/29/2007  Appeals of Claims Decisions: Appointment of Representatives; Fraud and Abuse; Guidelines for Writing Appeals Correspondence; Disclosure of Information  10/01/2007  5460 R1229CP  04/27/2007  Modification to the Model Medicare Redetermination Notice (for partly or fully unfavorable redeterminations) and the ALJ Filing Locations Where the Place of Service Was in Delaware, Kentucky, Puerto Rico, Virginia, &/or the US Virgin Islands  07/02/2007  5554
(Medicare Claims Processing Manual)
Rev #  Issue Date  Subject  Impl Date  CR#  R1211CP  03/30/2007  Change in the Amount in Controversy Requirement for Federal District Court Appeals  07/02/2007  5518 R1136CP  12/22/2006  Revisions to Procedure to Establish Good Cause and Qualified Independent Contractor Jurisdictions  04/02/2007  5386 R1069CP  09/29/2006  Reopenings and Revisions of Claim Determinations and Decisions  11/29/2006  4147 R985CP  06/16/2006  Appeals Updates  06/01/2006  5058 R862CP  02/17/2006  Appeals of Claims Decisions: Administrative Law Judge; Departmental Appeals Board; U.S. District Court Review  03/17/2006  4152 R724CP  10/21/2005  Appeals of Claims Decisions: Redeterminations and Reconsiderations Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006 12/16/2005  3939 R697CP  10/07/2005  Appeals of Claims Decision: Redeterminations and Reconsiderations (Implementation Date: May 1, 2005)  01/09/2006  3942 R695CP  10/07/2005  General Appeals Process in Initial Determinations (Implementation Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006)  01/09/2006  4019 R688CP  09/23/2005  Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for All Requests for Redetermination Received by FIs on or After May 1, 2005 and All Requests for 12/16/2005  3944
(Medicare Claims Processing Manual)
Rev #  Issue Date  Subject  Impl Date  CR#  Redetermination Received by Carriers on or After January 1, 2006)  R687CP  09/23/2005  Appeals of Claims Decisions: Redeterminations and Reconsiderations Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006 12/16/2005  3939 R679CP  09/16/2005  Medicare Redetermination Notice and Effect of the Redetermination  12/19/2005  4006 R678CP  09/16/2005  Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for All Requests for Redetermination Received by FIs on or After May 1, 2005 and All Requests for Redetermination Received by Carriers on or After January 1, 2006)  12/16/2005  3944 R677CP  09/16/2005  Appeals of Claims Decisions: Redeterminations and Reconsiderations Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006 05/01/2005  3939 R675CP  09/16/2005  Changes to Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Date: October 1, 2005)  10/03/2005  3943 R381CP  11/26/2004  Revisions and Corrections to Chapter 29 of the IOM Claims Processing Manual -Appeals  01/10/2005  3127 R1CP  10/01/2003  Initial Release of Manual  N/A N/A Back to top of Chapter
(Medicare Claims Processing Manual Crosswalk)
Medicare Claims Processing Manual Chapter 29 - Appeals of Claim Decisions Crosswalk  Note: QIO appeals instructions are to remain in the QIO Manual.  Some background material  is repeated here to enhance understanding. Chap.                                                                        Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description29 01 Foreword29 10 3790 12000 600 287 256 380 408 628 QIO-740 CMS Decisions Subject to the Administrative Appeals Process 29 20 3780 12000 600 287.4 256 383 408 628 QIO-740 Who may Appeal 29 30   600 287  383  628  Where to Appeal 29 30.1   600B       Social Security Office (SSO) 29 30.2          Part A Intermediary (FI) 29 30.2.1 FI Initial Determinations with Respect to Beneficiaries 29 30.2.2 Provider's Right to Appeal Certain Initial Determinations 29 30.2.3 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 30.3  12000        Part B Carrier 29 30.4 QIO-7400 Quality  Improvement Organization (QIO) 29 30.4.1         QIO-7400 QIO Reconsiderations and Appeals Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29
(Medicare Claims Processing Manual Crosswalk)
30.5 HMO-2403 Health Maintenance Organizations (HMO) and Managed Care + Choice Organizations 29 30.6         RO-3600 CMS Regional Office Responsibility 29 30.6.1         RO-3600 Assisting FIs to Obtain Documentation 29 30.6.2         RO-3610 Congressional Requests for Part A Reconsideration 29 30.7         PM-AB-02-111 Time Limits for Filing Appeals 29 30.8         PM-AB-02-111 Amount In Controversy Requirements 29 40 3781   287.4 257 383A  628A PM-AB-00-122 Part A Appeals Procedures 29 40.1 3781 Initial Determinations29 40.1.1 3781.1 Initial Determin ations With Respect to Beneficiaries 29 40.1.2 3781.2 287.2  381 Provider's Right to Appeal Certain Initial Determinations 29 40.1.3 3781.3 287.3  382 Situati ons Where Provider May Initiate Appeal 29 40.1.4 3781.4 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 40.1.5 3781.6 Finding Good Cause for the Late Filing of Appeal Requests 29 40.1.5.1 3781.6A General29 40.1.5.2 3781.6B         Establishment of Time Limit for Filing 29 40.1.5.3 3781.6C Conditions Which Establish Good Cause 29 40.1.5.4 3781.6D         Procedure to Establish Good Cause 29 40.1.5.5 3781.6E         Examples of Situations Where Good Cause Exists 29 40.1.5.6 3781.6F         Where Good Cause Is Not Found Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 40.1.6 3781.7         Assisting Handicapped Beneficiaries 29 40.2 3782         Reconsideration of a Part A Payment Determination 29
(Medicare Claims Processing Manual Crosswalk)
40.2.1 3782.1 Place and Manner of Filing Requests for Reconsideration 29 40.2.2 3782.2 Completing Form CMS-2649, Request for Reconsideration of Part A Health Insurance Benefits 29 40.2.3 3782.3         Routing the Reconsideration Request 29 40.2.4 3782.4 Acknowledging Receipt29 40.2.5 3782.5 Transferring and Dismissing Requests Which Involve Partial or No Jurisdiction, More Than One Component, Stay, or Issue 29 40.2.6 3782.7 Handling of Request--Beneficiary Appeals Before Initial Determination Is Made or After Initial Favorable Determination Is Made, But Before They Are Notified 29 40.2.7 3782.8         Withdrawal of Request 29 40.2.8 3782.9 Notifying Provider or Beneficiary Where There Is a Withdrawal 29 40.3 3783         Documenting Part A Reconsideration Requests 29 40.3.1 3783.1 Documentation Sources29 40.3.2 3783.2         Assembling the File 29 40.3.3 3783.3 PM-AB-00-122 Development29 40.4 3784 Evaluating the Evidence and Making the Reconsideration Determination 29 40.4.1 3784.1         Evaluating the Evidence Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29
(Medicare Claims Processing Manual Crosswalk)
40.4.2 3784.2 Review Prior to Reversal of Initial Payment Determination 29 40.4.3 3784.3        AB-90-12 Preparing the Determination 29 40.4.4 3784.4         Completing the Determination 29 40.4.5 3784.5         Notice of Further Appeal Rights 29 40.4.6 3784.6         Preventing Duplicate Payment in Reversal Cases 29 40.4.7 3784.7 Effect of a Reconsideration Determination and Effectuation 29 40.4.7.1 PM-A-00-32 Effectuating Favorable Final Appellate Decisions That a Beneficiary is Confined to Home  Regional Home Health Intermediaries (RHHIs) Only 29 40.4.8 3784.9         Reconsideration Guide Language 29 40.4.8.1 PM-A-01-21 Sample Paragraphs to Be Used by FIs in Sequence as Shown below 29 40.5 3785         Request for Hearing under Part A 29 40.5.1 3785.1         Determining The Amount In Controversy 29 40.5.2 3785.2         Request Filed With SSO 29 40.5.3 3785.3         Request For Hearing Filed With The FI 29 40.5.4 3785.4 Request For Hearings FI s Receive Pertaining To QIO or HMO 29 40.5.4.1 3785.4 Request For Hearings FI s Receive Pertaining To QIO 29 40.5.4.2 3785.4 Request For Hearings FI s Receive Pertaining To HMO 29 40.5.5 3785.5         Action On Incoming Requests Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 40.5.6 3785.6         Request For Claim File (Sent By Hearing Office) 29 40.5.7 3785.7         Examination Of Claim File 29 40.5.8 3785.8         Prehearing Case Review 29 40.5.9 3785.9         Routing The Hearing Claim File 29 40.5.10 3785.10         Standard Exhibits Referred To In 40.50-40.50.9 29
(Medicare Claims Processing Manual Crosswalk)
40.6 3786 Scope and Effect of OHA, SSA Administrative Law Judge (ALJ) Decisions under Part A 29 40.7 3787 Effectuation of Reversal of Decision Where There Was Subsequent Utilization of Benefits in the Same Benefit Period 29 40.8 3788         Effect of Court Decisions 29 40.9  12019        Right to Representation Under Part A 29 40.10 3790 Reconsiderations, Hearings, and Appeals Where a QIO Has Review Responsibility 29 40.10.1 3790.1 Reconsiderations29 40.10.2 3790.3 Hearings29 40.10.3 Appeals of Institutional Supplementary Medical Insurance (Part B) Claim Decisions 29 40.11 3798 287.5  Appeals by Hospitals of Diagnosis-related Group (DRG) Assignments under PPS 29 50           Part B Appeals Procedures - FIs 29 50.1 3791 FI - Review, And Fair Hearing - Supplemental Medical Insurance 29 50.2 3792 Extension Of  Time Limit For Filing An Appeal Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29
(Medicare Claims Processing Manual Crosswalk)
50.3 3793 Review29 50.3.1 3793.1 What Constitutes a Request for Review - Handling Beneficiary Inquiries 29 50.3.2 3793.2         Elements of a Review 29 50.3.3 3793.3 Actions Prior to Reversal of Initial Payment Decision 29 50.4 3794 The Hearing29 50.4.1 3794.1         Types of Hearings 29 50.4.2 3794.2         Issues Determined at the Hearing 29 50.4.3 3794.3         Request for Hearing 29 50.4.4 3794.4         Hearing Officer (HO) 29 50.4.5 3794.5         Preparation for the Hearing 29 50.4.6 3794.6         Conduct of an In-Person or Telephone Hearing 29 50.4.7 3794.7         Parties to the Hearing 29 50.4.8 3794.8         In-Person and Telephone Hearing Procedures 29 50.4.9 3794.9         On The Record Decision 29 50.4.10 3794.10  Hearing Decision29 50.4.11 3794.11         Content of Hearing Decision 29 50.4.12 3794.12         Style of Hearing Decision 29 50.4.13 3794.13         Effectuation of HO Decision 29 50.5 3795         RO Examination Of Hearing Decisions 29 50.6 3796         Fraud And Abuse Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09HO Pub. 10HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 50.6.1 3796.1         Disclosure of Information 29 50.7 3797         Requests For Hearing Before An ALJ 29 60  12000    383B  628B  Part B Appeals Procedures 29