evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 A nonpar ticipating suppli er has the same rights to appeal the  contracto rs determination in a n unassigned claim for medical equipm ent and suppli es if the contractor denies payment on the  basis of 1862( a)(1), 1834(a )(17)(B), 18 34(j)(1), or 1834 (a)(15) of the Act as a nonpar ticipating or participating suppli er has in a ssigned claims.  Th ese rights of  appeal a lso extend to de terminations that a refund is re quired either because the supplier knew or should ha ve known tha t Medicare would not pa y for the item or service (See 1834 (j)(4)), or becaus e the beneficiary was not pr operly informed in w riting with an Advan ced B eneficiary Notice of N on C overage (ABN) that Medicare would not pa y or was unlike ly to pa y for the item or service. While the time  limits  in 310 a pply for filing r equests for redetermination, ref unds  must be  made within the  time  limits sp ecified in Chapter 30.  An a dverse advance determination of  coverage under  1834(a)(15 ) of the Act is not a n initia l determination on a  claim for payment for items furnishe d and, ther efore, is not a ppeal able;   A non- participating physician not billing on an assigned basis but who m ay be responsible f or making a refund to t he beneficiary under 184 2(l)(1) of the Act for services furnishe d to a  beneficiary that are denied on the  basis of  sectio n 1862(a)(1 ) of the Act, has party status with respect to the  claim at issu e;   A provide r or suppli er who other wise does not ha ve the right to a ppeal ma y appeal w hen the  beneficiary dies and there is no othe r party available to appeal.  S ee 210.1 for information on determining  whether there is another party available to appeal;
(Medicare Claims Processing Manual)
 A Medicaid S tate agency or party author ized to a ct on be half of the State. Medicaid State ag encies have party  status at the  redetermination level  (and subs equent levels) for claims for ite ms or services in volving a be neficiary who is e nroll ed to r eceive benefits unde r both Me dicare and  Medicaid, but only  if the  Medicaid State  agency has ma de payment for, or may be  liable  for su ch items or s ervices, and only i f the State  agency has fil ed a time ly request for re determination for such items or s ervices.  (See 42 C FR 405.90 8); and   Any individua l whose  rights with re spect to the  particular claim being reviewed may be aff ected by such review and any other individua l whose  rights with respect to suppl ementary medical insu rance benefits ma y be prejudiced by the decision (e .g., an individua l or entity liable for payment unde r 42 CFR subpar t E 424.60 i n the  case  of a deceased beneficiary).  Neither the contractor  nor CMS is considered a  party to an appeal  at the redetermination or  reconside ration levels, and theref ore does not ha ve the right to a ppeal or  to participate as a party at this sta ge in the  administra tive appeals p rocess.  CMS or a contractor may choos e to par ticipate in an ALJ hearing, become a party to an ALJ hearing (with C MS approval), or may r ecom mend that the  Administrative  QIC (AdQIC) refer an ALJ decision or  dismiss al to the Appeals C ounc il for rev iew unde r its own motion re view authority.  At tim es, an ALJ may ask for a contractors or QICs input to a  hear ing.  This doe s not c hange the contracto rs party status.
(Medicare Claims Processing Manual)
NOTE: While a representative may request an appeal on be half of the party that he/she re presents, the  representative is not a  party to the  appeal sol ely by virtue of being a re presentative.  (See 270 for the rights and responsibilitie s of a representative.) The provide r of the  item or service denied may represent the  individua l, but m ay not impose  any financial liability on the  individua l in connection with su ch representation.  If limita tion on li ability is involv ed, the  provide r of the item or service may represent the  individua l only if the provider waives any rights for payment from the  individua l with re spect to the  services or items involve d in the  appeal.   210.1 - Provider or Supplier Appeals When the Beneficiary is Deceased  (Rev. 695, Issued:  10- 07-05; Effective:  05 -01-05; Implementation:  01 -09-06)  When a provider or supplier appeals on behalf of a deceased beneficiary and the provider or supplier otherwise does not have the right to appeal, the MAC must determine whether another party is available to appeal by taking either of the following actions:    The MAC may send a letter to the last known address of the beneficiary, or to the beneficiary's estate, if known.  The letter should advise the beneficiary's estate (or anyone taking responsibility for the deceased's bills for medical or other health servi ces) of the right to appeal the claim denial.  The letter also should provide information that the provider or supplier wishes to appeal.  The letter should provide the beneficiary's estate with the following three options:   o Option 1: I wish to appeal this claim.   o Option 2: I am not available to appeal, please process the provider's appeal and let me know   of the result.   o Option 3: I am available to appeal, but do not wish to exercise my right to appeal.
(Medicare Claims Processing Manual)
o Option 2: I am not available to appeal, please process the provider's appeal and let me know   of the result.   o Option 3: I am available to appeal, but do not wish to exercise my right to appeal.   The MAC should allow the estate at least 10 days to respond, or the remainder of the time frame for requesting an appeal --  whichever is greater.  If the estate does not respond in the allotted time frame, the MAC should annotate the file that no other par ty is available to appeal and continue to process the provider's or supplier's appeal.  If the estate responds that it is available and wishes to appeal, the MAC should continue with the appeal and notify the provider or supplier of the results.  If the estate indicates that it is not available to appeal, then the MAC s hould continue to process the appeal and notify the beneficiary's estate of the decision.  If the estate indicates that it is available, but does not want to appeal, the MAC should dismiss the provider or supplier's request on the basis that there is another party available, even though the party does not intend to pursue the appeal; or   The MAC may send a letter to the provider or supplier to request written confirmation that they are not aware of any other party available to appeal.  The MAC should allow the provider or supplier 10 days to provide confirmation.  If the MAC does not recei ve written confirmation within 15 days, it should dismiss the appeal on the basis that the provider or supplier did not confirm that there was no other party available to appeal.   220 - Steps in the Appeals Process:  Overview  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
220 - Steps in the Appeals Process:  Overview  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Regulations a t 42 C FR 405.940- 405.942 pr ovide  that a party to a redetermination th at is diss atisfied with an initia l determination m ay request that the contractor make a redetermination. The  request for redetermination must be  filed within 120 da ys after the date of receipt of  the noti ce of the initia l determination ( the notice of initia l determination is p resumed to be  received 5 da ys after the date of the notice unless there is evidence to the contrary). Contracto rs cannot acc ept an appeal for which no initi al determination ha s been m ade. The  parties specified in 210 who ar e dissatisfied with a  determination on th eir Part A or  B claim have appeal rights.  The appeals process consists of  five levels. The  appellant must b egin the appeal at the first level after receiving a n initia l determination. E ach l evel, after the initia l determination, ha s procedura l steps the  appellant must ta ke before appealin g to the  next level. Each l evel is dis cussed in de tail in subs equent sections. I f the appellant meets the procedu ral steps at a specific level (including the  amount in controve rsy (AIC) requirement if appli cable), the appellant (and all oth er parties to the  appeal decision)  is th en afforded the right to a ppeal any determination or decision to the  next level in the  process. The  appellant may exercise  the right to a ppeal a ny determination or  decision to the  next higher level, until a ppeal r ights are exhausted. Althoug h ther e are five distin ct levels in the  Medicare appea ls process, the  redetermination, l evel 1, is the only level in the  appeals  process th at the contractor performs.
(Medicare Claims Processing Manual)
When an appellant requests a reconside ration with a  QIC (level 2), the contractor  must p repare and forward the case file to the  QIC.  Further, the contractor  may have effectuation re sponsibilitie s for decisions m ade by the QIC. The contractor, how ever, does not ha ve re sponsibili ty for reviewing the QICs decision f or accur acy. When an appellant requests an Administ rative Law Judge  (ALJ) hearing or review by an attorney adjudicator (level 3), the QIC must p repare and forward the  case file to the  OMHA.  Further, the contractor may have effectuation r esponsibilitie s for decisions m ade at OMHA, D epartmental App eals Board (DAB)/Appeals C ounc il, and Fe deral C ourt levels.  In the  chart below, l evels 1  4 ar e part of the Administra tive App eals P rocess.  If an appellant ha s compl eted all the  first 4 st eps of  the administra tive appeals process and is still d issatisfied, the  appellant may appeal to the Federal courts, pr ovided the  appellant satisfies the requirements for obtaining judicial review.   CHART  1 - The Med icare Fee-for-Service Appeals P rocess  APPEAL LEVEL TIME LIMIT FOR FILING REQUE ST MONETA RY THRESHOLD TO B E MET 1. Redetermination 120 d ays from d ate of receipt of the  notice initia l determination None  2. Reconsid eration 180 d ays from d ate of receipt of the  redetermination* None  3. Administ rative Law Judge (ALJ) Hearing 60 days from the  date of receipt of the  reconside ration Current AIC requirements can be  found on CMS.gov at: http://www.c ms.gov/ Medicare/Appeals-and-Grievances/Or gMedFFS Appeals/HearingsA LJ.html .
(Medicare Claims Processing Manual)
See 250 for additional information.  4. Departmental Appeals B oard (DAB ) Review/App eals Council 60 days from the  date of receipt of the  ALJ hearing decision  None  5. Federal Court Review 60 days from d ate of receipt of the Appeals C ounc il decision Current AIC requirement can be  found on CMS.gov at: http://www.c ms.gov/ Medicare/Appeals-and-Grievances/Or gMedFFS Appeals/Review-Federal-Distric t-Court.html .  See 345 for additional information   *NOTE: If a party  requests Q IC review of a contra ctors dismissal of a r equest for re determination, the  time  limit for f iling a r equest for reconside ration is 60 da ys from the  date of receipt of the  contra ctors dismissal notice.  230 - Where to Appeal  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Where a party must f ile an appeal d epends on the  level of appeal.  The  chart below indi cates wh ere appellants should f ile appeal requests for each l evel of appeal.  CHART  2 - Where to File an Appeal  LEVEL  WHERE TO F ILE AN AP PEAL    Part A*  Part B  DME   Redetermination  MAC   MAC   MAC  LEVEL  WHERE TO F ILE AN AP PEAL   Reconsid eration  QIC   QIC   QIC   ALJ H earing  HHS OM HA Ce ntral Operations    HHS OM HA Ce ntral Operations    HHS OM HA Ce ntral Operations    Appeals Coun cil Review  Appeals Coun cil  Appeals Coun cil  Appeals Coun cil  *Includes part B claims f iled with the  Part A  Medicare Administrative  Contra ctor (M AC).  240 - Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. T ime Limits for Each Level of Appeal The time  limits f or filing appeals va ry according to the  type of appeal:
(Medicare Claims Processing Manual)
A. T ime Limits for Each Level of Appeal The time  limits f or filing appeals va ry according to the  type of appeal:   Redetermination - The time  limit f or filing a request for redetermination is  120 da ys from the  date of receipt of  the Medicare Summ ary Notice (MSN) or Remitta nce Advi ce (RA).  See 240. 1-240.5 f or clarifications  and exceptions to this rule.)   QIC Recon sideration - The time  limit f or filing a request for reconside ration is 180 da ys from the  date of receipt of  the notice of the redetermination.  I f a party requests Q IC review of a MACs dismissal of a r equest for re determination, the  time  limit for filing is 60 da ys from  the date of receipt of the  MACs dismissal noti ce.   ALJ Hearing - The time  limit for filing a request for an A LJ hearing is 60 days from the  date of receipt o f the reconsidera tion not ice.   Appeals C ounc il Review - The time  limit f or filing a  request for re view by the Appe als C ounc il is 60 da ys from the  date of receipt of the ALJs or attorney adjudicators de cision.   Judi cial R eview - The time limit f or filing for judicial review is 60 da ys from the da te of the Appeals C ounc il's decision.  A request filed with the  A/B MAC (A), (B), (HHH), or DME MAC is c onside red to have been filed as of the date the MAC recei ved it.  The  MAC  comput es the time  limit f or requesting a redetermination b y allowin g 5 additiona l days beyond the time  limit ( 120 da ys for a redetermination)  from the  date of the p revious noti ce.  This a llows a  5-day period for mail delivery.  The  MAC  allows f or addition al time  if there is evidence that the mail delivery was longer than 5 days.
(Medicare Claims Processing Manual)
NOTE:  When the beneficiary preference is to have all documents converted into an accessible format, MACs shall make allowances for additional delivery time of the accessible format. The MAC shall also provide allowance for a delayed response as a result of a beneficiary having sought and received help from an auxiliary resource (such as a SHIP or senior center), on account of his or her disability, in order to be able to file an appeal (also see 240.2).   When the  filing d eadline  for a re determination e nds on a Saturda y, Sunda y, legal holida y, or any othe r nonw ork day, the  MAC shall apply a r ollover period that ex tends the  filing de adline to the  first w orking day after the Saturda y, Sunda y, legal holida y, or othe r nonw ork day.  For ex ampl e, if the  filing d eadline  for a redetermination falls on the  Saturday  before Columbus Da y, the  filing d eadline  is ex tended to the  first working day after the Columbus Day holida y.  These time  limits ma y be extended if good c ause for late filing is shown.  (See 240.1- 240.5.)  W hen a redetermination re quest appears to be  filed late, the MAC  makes a finding of good cause  using the guidelines in 240.2 through 240.4 bef ore taking any other action on the  appeal.   B. Extension of Time Limit for Filing a R equest for Redetermination  The time  limit f or filing a request for redetermination m ay be extended in cer tain situ ations.  G enerally, provider s, ph ysicians or  other suppli ers are expected to file appeal re quests on a time ly basis.  A re quest from a  provider , physician, or othe r suppli er to extend the  period for filing the request for redetermination should not be  routine ly granted and such requests warrant car eful examination.  F or a beneficiary request, more lenience should be  given.
(Medicare Claims Processing Manual)
Upon re quest by the party that has misse d the  filing deadline, the A/B MAC (A), (B), (HHH), or DME MAC  may extend the per iod for filing the request for redetermination.  The procedures for finding good c ause to excuse late filing ar e discussed below.  240.1 - Good Cause  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If an appeal request is f iled late, the applicable MAC  may extend the  time  limit f or filing an appeal if good cause is shown.  T he MAC  resolves the issue  of whether good cause exists b efore taking any other action on the appeal.  Whenever a MAC makes a finding for good cause for late filing, the MAC shall document the reason for that finding in the redetermination decision letter.  If no decision letter is issued (i.e., a decision fully favorable to the appellant is made, which currently does not require issuance of a redetermination decision letter), then the reason t he MAC  found th at good ca use exists f or late filing shall be documented in the redetermination  case file.   NOTE:  A finding by the MAC  that good cause  exists f or late filing for the redetermination doe s not m ean that the party is then excused from the  time ly filing rules for the reconside ration.  240.2 - Conditions and Examples That May Establish Good Cause for Late Filing by Beneficiaries (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A.  Conditions  Good c ause m ay be found when the  record c learly show s, or the  beneficiary alleges, that the de lay in filing was due  to one of the  follo wing:   Circumstan ces b eyond t he beneficiarys control, inc luding m ental or physi cal impairme nt (e.g., disabilit y, ex tended illn ess) or signifi cant c ommuni cation diffi culties;
(Medicare Claims Processing Manual)
 Incorrect or in compl ete information about the  subject claim and/or appe al was furnish ed by offi cial sources (CMS, the  contra ctor, or the  Social Security Administration)  to the  beneficiary (e.g., a party is not notifi ed of he r app eal rights or a party r eceives inaccurate information r egarding a filing deadlin e);  NOT E:  Whenever a b eneficiary is not notifi ed of his/h er app eal rights or of the time  limits for filing, goo d cause must be  found.   Delay resulting from e fforts by  the beneficiary to secure  supporting ev idence, where the beneficiary did not realize that the  evidence could be  submitte d after filing the  request;   When destruction of or othe r damage to the  beneficiarys records w as responsible for the  delay in filing ( e.g., a fir e, natural disast er);   Unusual or una voidable  circumstan ces, the  natu re of w hich demonstrates that the b eneficiary could not reasonably be  expected to h ave been aware of the  need to file time ly;   Serious illn ess which prevented the  party  from  contacting the  contra ctor in pe rson, in w riting, or through a fri end, relative , or othe r person;    A death or s erious illn ess in his or he r imme diate  family;     A request was sent to a Gove rnment agency in good faith w ithin the  time  limit, and the  request did not reach the  appropriate  contractor until afte r the time period to file  a request expired; or   Delay due to additional time required to produce the beneficiarys Medicare documents (such as an MSN) in an accessible format (e.g., large print, Braille, etc.);     Delay as the result of an individual having sought and received help from an auxiliary resource (such as a SHIP or senior center), due to his or her disability, in order to be able to file the appeal.  B.  Examples
(Medicare Claims Processing Manual)
 Delay as the result of an individual having sought and received help from an auxiliary resource (such as a SHIP or senior center), due to his or her disability, in order to be able to file the appeal.  B.  Examples  Follo wing are  exampl es of cases where good c ause for late  filing is found.  This list is illu strative only and not all -inclusive:   Beneficiary was hospitaliz ed and ex tremely ill, c ausing a de lay in filing;    Beneficiary is deceased.  Her husband, as r epresentative  of the  beneficiarys estate, died during the appeals filing p eriod.  R equest was then filed late  by the d eceas ed husband s executor;    The denial noti ce sent to the  beneficiary did not s pecify  the time  limit for fil ing for the  redetermination; and    The request was received after, but c lose to, the  last day  to file , and the be neficiary claims that the  request was submitte d time ly.  240.3 - Conditions and Examples T hat May Establish Good Cause for Late Filing by Providers, Physicians, or Other  Supp liers (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  In general, A/B MACs (A), (B), (HHH), and DME MACs s hould not routine ly find g ood c ause w hen a provider, physi cian or othe r suppli er submits an unt imely appeal request.  H owever, good c ause may  be found w hen the r ecord c learly show s, or the provider, physi cian o r other suppli er alleges and the  record does not ne gate, that the  delay in filing w as due  to one  of the  follo wing:   Incorrect or in compl ete information about the  subject claim and/or appe al was furnish ed by official sou rces (CMS, the  MACs, or the  Social Security Administration)  to the  provider, physi cian, or othe r suppli er; or
(Medicare Claims Processing Manual)
 Unavoidable  circumsta nces that pr event ed the  provider, physi cian, or othe r suppli er from time ly filing a request for re determination.  Una voidable  circumstan ces e ncompass situations that are  beyond the  provider, phy sician or suppli ers control, suc h as major floods, fir es, tornados, and othe r natural c atastroph es.  NOT E:  Failure  of a bill ing company or othe r consultant ( that the  provider, physi cian, or othe r suppli er has retained) to timely submit appe als or othe r information is N OT grounds for finding good c ause for late  filing.  T he MAC do es not find good c ause w here the provider, physi cian, or othe r suppli er claims that la ck of busine ss offi ce manag ement skills or ex pertise c aused the  late filing.   240.4  Good Cause - Administrative Relief Following a Disaster  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10 - 01-19)  When a disaster occurs, whether natural or man -made, MACs shall anticipate both an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks.  For appeals purposes, as defined in this IOM, a disaster area is declared by the Federal Emergency Management Agency (FEMA).  In disaster situations, MACs that process appeals for beneficiaries, providers, and suppliers affected by a disaster shall exercise good cause in accorda nce with the regulations and follow the guidance below regarding how to process Fee -for-Service appeal requests in an area(s) declared by FEMA as a disaster area.     When a Presidential declaration occurs, the HHS Secretary may, under section 319 of the Public Health Service Act, declare that a Public Health Emergency (PHE) exists in the affected State.  Once a PHE is declared, section 1135 of the Social Security Act a uthorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements as determined necessary by CMS.  A. Definition of Disaster