evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
10.5.4 - Documenting the Telephone Reopening  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  The information received during the telephone reopening (especially the date of the call) must be either: (1) documented on a reopening documentation form; or (2) logged into the contractors computer system.   All documentation must be assigned a control number. Any additional documentation received must be recorded into the contractor system or attached to th e form.  The telephone reopening control number is recorded on all documents received that are associated with the telephone reopening, if applicable.  The documents are included in the file.   Although documentation should rarely be necessary during a tele phone reopening, the documentation must be made a part of the file and be available if an appeal is requested based on any revised determination issued as a result of the reopening.  All documentation should be maintained in a manner that allows for future  audits.  10.5.5 - Monitoring the Telephone Reopening  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  CMS may review this function at any time so the contractor may want to develop and maintain records on a monitoring/quality assurance process.   10.6 - Timeframes to Reopen Claim Determinations  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  Our regulations establish timeframes that restrict the ability of the contractor to reopen claim determinations.  See 42 CFR 405.980(b) and (c)  for the timeframes for reopenings.  The specific timeframes for contractor -initiated and party -requested reopenings are detailed below.   10.6.1 - Timeframes for Contractor Initiated Reopenings  (Rev. 3568, Issued: 07- 29-16, Effective: 09 -30-16, Implementation: 09- 30-16)  A contractor may reopen and revise its initial determination or redetermination on its own motion:    Within 1 year from the date of the initial determination or redetermination for any reason; or
(Medicare Claims Processing Manual)
A contractor may reopen and revise its initial determination or redetermination on its own motion:    Within 1 year from the date of the initial determination or redetermination for any reason; or    Within 4 yea rs from the date of the initial determination or redetermination for good cause as defined in 10.11; or    At any time if:   o There exists reliable evidence that the initial determination was procured by fraud or similar fault as defined in 42 CFR 405.902 ; or  o The initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based.  Third party payer error does not constitute clerical error as defined in 10.4; or,   At any time to effectuate a coverage decision issued under 42 CFR 426.460(b)(1)(i) , 426.488(b) and (c)  or 426.560 (b)(1)(i)  appeals process.   10.6.2 - Timeframes for Party Requested Reopenings  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A party may request a contractor reopen and revise its initial determination or redetermination under the following conditions:    With in 1 year from the date of the initial determination or redetermination for any reason; or    Within 4 years from the date of the initial determination or redetermination for good cause as defined in 10.11; or,   At any time if the initial determination is u nfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based.  Third party payer error does not constitute clerical error as defined in 10.4.
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While a contractor can r eopen at any time under the limited criterion set forth above to correct an unfavorable determination, CMS does not expect that a contractor would regularly grant these requests, especially for older claims where the claims history is not readily available.  Both the contractor and the provider/physician/supplier have a reasonable expectation to administrative finality in the processing of their claims.  Additionally, administrative efficiency and the ability of a Medicare contractor to continue vital funct ions (i.e., process Medicare claims and process appeal requests) require that contractors grant such requests rarely.   10.6.3 - Timeframes for Adjudicator to Reopen  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)A   QIC, ALJ or  the AC may reopen and revise its reconsideration, hearing decision or review, respectively, under the following conditions:    Within 180 days from the date of its decision for good cause in accordance with 42 CFR 405.986 ; or,    At any time if the reconsideration, hearing decision or review was procured by fraud or simi lar fault.   10.6.4 - Timeframes When a Party Requests an Adjudicator Reopen Their Decisions  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A party may request a QIC, ALJ or the AC reopen and revise its reconsideration, hearin g decision or review within 180 days from the date of the reconsideration, hearing decision or review, as applicable, for good cause in accordance with 42 CFR 405.986 .  10.7 - Timeframes to Complete a Reopening Requested by a Party  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)
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10.7 - Timeframes to Complete a Reopening Requested by a Party  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)  There are no timeframes established in statute or regulati on governing the timeframes for a contractor to complete a reopening action.  However, a party to an initial determination has a reasonable expectation to the administrative finality of a determination issued by Medicare.  Therefore, this section sets out timeframes to complete the reopening action once the reopening has been initiated.  These timeframes apply only to those reopening requests that are requested by the party to the initial determination.  These timeframes do not apply to contractor initiated  reopenings.   For those reopenings requested by a party that the contractor agrees to reopen, the contractor shall complete the reopening action 60 days from the date of receipt of the partys reopening request in the corporate mailroom, receipt in a secur e Internet portal/application,  or receipt of the telephone request.  This does not apply to big box cases defined as aggregated requests filed by a provider, physician, or other supplier that involve 40 or more beneficiaries/claims and $40,000 or more i n controversy.   10.8 - Notice of a Revised Determination or Decision  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)
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10.8 - Notice of a Revised Determination or Decision  (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10- 03-11)  If the reopening action results in a revised determination or decision that results in payment to a provider, physician, or supplier, a revised electronic or paper remittance advice notice must be issued by the Medicare contractor and will satisfy the notice requirements.  If applicable, a revised Medicare Summary Notice will suffice for notice to the beneficiary  in the above instances.  If the reopening action results in an adverse revised determination or decision the contractor shall mail, or if approved by CMS, transmit via a secure Internet portal/application a letter that states the rationale and basis for the reopening and revision and any right to appeal.  The timeframe to request the appeal would be based on the date of the contractors revised determination.  If the contractor cannot change the original determination or chooses to not accept the request, the contractor should inform the requestor that the contractor cannot process their reopening request.  If the request is over the telephone, the contractor can verbally inform the caller that they cannot process their request.  If it is a written reopenin g request submitted via hard copy or a secure Internet portal/application, the contractor shall send a brief letter via mail or, if approved by CMS, a secure Internet portal/application, informing the requestor that they cannot process the request.  The contractor should state that their decision to not reopen a claim determination is not an initial determination and is therefore not appealable.   10.9 - Revised Determination or Decision  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  A revised determination or decision is one in which:    The end result is changed (e.g., a service previously found to be covered is now found not to be covered or the allowable charge for the service is determined to be incorrect); or    The end r esult is not changed, but a party might be disadvantaged by the revision (e.g., a request for payment on a claim previously disallowed because the services were not medically necessary and therefore subject to the limitation on liability provisions, is now to be disallowed on a basis that precludes consideration of limitation on liability).
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10.10 - Effect of a Revised Determination or Decision  (Rev. 1069, Issued: 09- 29-06, Effective: 11- 29-06, Implementation: 11- 29-06)  The revision of an initial determina tion is binding on all parties unless a party files a written request for a redetermination of the revised determination that is accepted and processed.  The request for a redetermination must be filed within 120 days from the date of the revised initial d etermination.  The revision of a redetermination is binding on all parties unless a party files a written request for a QIC reconsideration that is accepted and processed.   10.11 - Good Cause for Reopening (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09 -30-16)  On its own initiative or at the request of party (see IOM Pub. 100- 04, chapter 29, 110 for the definition of a party), a contractor may reopen an initial determination or redetermination within 4 years  from the date of the initial determination  or redetermination  when good cause exists.  However, good cause is not required for reopening of claims for up to 1 year from the date of the initial determination or redetermination.  Under 42 CFR 405.986 , good cause exists when:    There is new and material evidence that was not available or known at the time of the determination or decision and may result in a different conclusion; or    The evidence that was considered in making the determination or decision clearly shows on its face that an obvious error was made at the time of the determination or decision.  A contractors decision to reopen based on the existence of good cause, or refusal to reopen after determining good cause does not exist, is not subject to appeal.  See 42 CFR 405.926(l) , and 405.980(a)(5) .
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NOTE:   Third par ty payer error in making a primary payment determination does not constitute good cause for the purposes of reopening an initial determination or redetermination when Medicare processed the claim in accordance with the information in its system of records or on the claim form.  Contractors may only reopen for third party payer error under the within one year for any reason standard.  This is true for both contractor initiated reopenings as well as reopenings requested by a party.  All providers and suppli ers have a legal obligation to determine the correct primary payer when billing Medicare.  Failure to do so, regardless of third party payer error, does not constitute good cause that will permit reopening beyond one year.  Information regarding such error does not constitute new and material evidence.   10.11.1 - What Constitutes New and Material Evidence  (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  New and material evidence is one of the means for establishing good cause to  reopen an initial determination or redetermination.  New and material evidence is evidence that:   1. Was not readily available or known to the person or entity requesting/initiating the reopening at the time of the initial determination or redetermination ; and   2. May result in a conclusion different from that reached in the initial determination or redetermination.  For example, data analysis that identifies a high error rate or pattern of potential overutilization on the part of a provider or supplier is one example of evidence that is not readily available or known to a contractor at the time it made its initial determination, and may cause the contractor to believe its initial determinations for the claims of the provider or supplier were incorrect.
(Medicare Claims Processing Manual)
Evidence may include any record used in the provision of medical care that supports whether or not the service was covered, medically necessary, and provided as billed.  This includes medical records, progress notes, orders, procedure reports, invoices, pr oofs of delivery, or other documentation as required by CMS policy.  However, as explained further below, any such evidence submitted by a party must satisfy the good cause standard set forth in 405.986 (i.e., that it is new and material evidence (as desc ribed above), or demonstrates that the evidence considered in making the initial determination or redetermination clearly shows on its face that an obvious error was made at the time of the determination or decision).  10.11.2 - Policies Related to Good Cause Reopenings for New and Material Evidence  (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  In determining whether good cause exists for reopening an initial determination or redetermination, the contractor considers whether evidence is new and material from the perspective of the person or entity requesting or initiating the reopening.   When a party requests a reopening of an initial determination or redetermination for good cause based on the submission of new and material e vidence, the following policies apply:    The mere submission of additional evidence is not necessarily sufficient to establish good cause to reopen an initial determination or decision.  The information must be new, (i.e., not readily available or known t o exist at the time of the initial determination) as well as material (i.e., may result in a different conclusion).  A party should explain how the information constitutes new and material evidence that establishes good cause.  If the contractor is unable to determine whether the information submitted with a reopening request constitutes new and material evidence, the contractor may decide not to grant the reopening.    When a request for reopening is submitted with new and material evidence, but additional i nformation or evidence is needed before a proper revised determination or decision can be made, the contractor may contact the party seeking the reopening, and request that they obtain and submit the additional information.  If the person or entity request ing the reopening cannot obtain the additional information, the Medicare contractor assists to the extent that it is reasonably able to do so.
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When a Medicare contractor initiates a reopening of an initial determination or redetermination for good cause based on the existence of new and material evidence, the following policies apply:    The contractor is responsible for clearly documenting in the case file the new and material evidence that represents good cause for reopening.    In order to promote administrative efficiency, Medicare does not generally require that a party submit supporting medical documentation with the initial claim.  Therefore, if a medical record or other supporting documentation was not utilized when a contractor made an initial determination, because it was not requested or was not provided, then the content of any medical records or supporting documentation which are subsequently requested by the contractor during the course of its review would constitute new evidence.   10.11.3 - What Constitutes Error on the Face of the Evidence (Rev. 1671, Issued:  01- 16-09; Effective/Implementation Date:  02 -16-09)  Error on the face of the evidence exists if it is clear that the determination or decision was incorrect based on all evidence i n file on which the determination or decision was based, or any evidence of record anywhere in the contractors Medicare file or in CMS files at the time such determination or decision was made.   10.12 - Change in Substantive Law or Interpretative Policy  (Rev. 3568, Issued: 07- 29-16, Effective: 09- 30-16, Implementation: 09- 30-16)  A change of legal interpretation or policy by CMS in a regulation, CMS ruling or CMS general instruction, or a change in legal interpretation or policy by SSA in a regulation, SSA ruling or SSA general instruction in entitlement appeals, whether made in response to judicial precedent or otherwise, is not a basis for reopening a determination or decision under this section.  This provision does not preclude contractors from conducti ng reopenings to effectuate coverage decisions issued under 42 CFR 42 CFR 426.460(b)(1)(i) , 426.488 (b) and (c) , or 426.560(b)(1)(i)  appeals process..  10.13  System and Processing Requirements for Use of Secure Internet Portal/Application to Support Reopening Activities (Rev. 2241; Issued: 06- 17-11, Effective: 10- 01-11, Implementation: 10 -03-11)
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Contractors who develop and utilize a secure Internet portal/application for reopening purposes shall ensure, at a minimum:    CMS approves (i.e., Contract Manager or Project Officer, if applicable, and Appeals Business Function Lead) the proposed portal/application and usage prior to development and implementation.   The portal/application fully complies and has been tested to ensure compliance with all CMS system security requirements regarding protected health information prior to implementation/usage.    The secure Internet portal/application includes a formal registration process that validates the signature.  This process shall include, at a minimum, use of restricted user identifiers (IDs) and passwords. Contractors shall include an indication and/or description of the validation methodology in the appeals case file should an appeal on the item/service reopened be requested.    Templates for submission of electronic reopening request shall include, at a minimum, a method for authe nticating that the party has completed the portal/application registration process and has been properly identified by the system as an appropriate user.    Contractors utilizing an approved portal/application shall provide education to parties to the reopen ing regarding system capabilities/limitations prior to implementation and utilization of the secure portal/application.    Contractors shall also educate parties to the reopening that participation/enrollment in the secure portal/application is at the discre tion of the party and the party bears the responsibility for the authenticity of the information being attested to.    Appropriate procedures are in place to provide parties with confirmation of receipt of the reopening request via secure Internet/portal and  verbiage instructing the parties not to submit additional reopening requests for the same item or service via different venue (hard copy mail or telephone).    Contractors utilizing a secure portal/application shall ensure that there is a process in place b y which a party can submit additional documentation/materials concurrent with the reopening request.  The portal/application shall have the capability to accept additional documentation and/or other materials to support reopening requests.
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 Refusal to reop en and adverse revised determination notices transmitted via a secure Internet portal/application shall comply with the timeliness and content requirements as outlined in the Pub. 100- 04, chapter 34.  In addition, contractors shall provide hard copy decisi on notices to parties to the reopening, as required, who do not have access to the secure Internet portal/application.  The notices must be mailed and/or otherwise transmitted concurrently (i.e., mailed on the same day the notice is transmitted via the sec ure portal/application).   Contractors utilizing a secure Internet portal/application shall include the adverse revised determination/decision notice and any other related materials in the appeals case file if a valid appeal on the item/service is later req uested.    Contractors shall also ensure that parties may save and print the revised adverse determination/decision notice or refusal to reopen notice and that the secure portal/application includes a mechanism by which the date/time of the notification is tracked/marked both in the system and on any printed decision notices so as to adequately inform the party of timeframes for ensuring timely submission of future appeal requests.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R4219CP  01/25/2019  Update to Pub. 100- 04 Chapter 34 to Provide Language -Only Changes for the New Medicare Card Project  02/26/2019  11115  R3568CP  07/29/2016  Reopenings Update -  Changes to Chapter 34  09/30/2016  9639 R2241CP  06/17/2011  Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Reopenings Via a Secure Internet Portal/Application  10/03/2011  7420 R1671CP  01/16/2009  Clarification of Requirements for New and Material Evidence as Good Cause for Reopening 02/16/2009  6157 R1069CP  09/29/2006  Initial Release of Chapter -Reopenings and Revisions of Claim Determinations and Decisions  11/29/2006  4147 Back to top of chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 36  Competitive Bidding  Table of Contents (Rev. 11427, 05-20-22)
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Transmittals for Chapter 36  01 - Foreword  10 - Background  10.1 - Competitive Bidding Implementation Contractor (CBIC)  10.2 - Definitions  20 - DMEPOS Competitive Bidding Process  20.1 - Items Subject to Competitive Bidding  20.2 - Competitive Bidding Areas (CBAs)  20.3 - No Administrative or Judicial Review  20.4 - Eligibility Requirements to Submit a Bid  20.5 - Becoming a Contract Supplier  20.5.1 - Small Suppliers and Networks  20.5.2 - Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs)  20.5.3 - Home Health Agencies  20.5.3.1 - Mail -Order Suppliers for Diabetic Supplies  20.5.4 - Items Furnished on a Mail Order Basis  20.5.4.1 - Mail -Order Suppliers for Diabetic Supplies  20.6 - Noncontract Suppliers  20.6.1 - Special Rules for Certain Rented Durable Medical Equipment (DME), Oxygen and Oxygen Equipment (Grandfathered Suppliers and Items)  20.6.1.1 - Requirements for Grandfathered Suppliers  20.6.1.1.1 - Eligibility  20.6.1.1.2 - Servicing Current Beneficiaries  20.6.1.1.3 - Notification to Beneficiaries by Suppliers that Choose to Become Grandfathered Suppliers  20.6.1.1.4 - Notification to Beneficiaries for Suppliers that Choose Not to Become Grandfathered Suppliers  20.6.2 - New Period of Continuous Use  20.6.3 - Picking Up Equipment  20.6.4 - Transfer of Title for Oxygen Equipment and Capped Rental DME  20.6.5 - Capped Rental DME Furnished Prior to January 1, 2006  20.7 - Use of Advanced Beneficiary Notice (ABNs)  30 - Contract Supplier Responsibilities  30.1 -  Compliance with Laws and Regulations  30.2 -  Requirement to Maintain Medicare Billing Privileges and Accreditation  30.3 -  Servicing the Entire Geographic Area of a CBA  30.4 -  Prescr iption for Particular Brand, Item, or Mode of Delivery  30.5 -  No Discrimination Against Beneficiaries  30.6 -  Quarterly Reports  30.7 -  Reporting Change of Ownership (CHOW)  30.8 -  Submission of Claims  30.9 -  Breach of Contract  30.10 -  Request for Reconsideration 40 - Payment Rules  40.1 -  Single Payment Amount  40.2 -  Conditions for Payment