evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 A copy of this noti ce,  The bill you received for the services, and  The payment receipt,  your canc elled check, or  any other evidence showi ng that you have already paid (provide r's name) for the services a t issu e.  You should f ile your written request for refund within 6 months of  the date of this noti ce.  If, as the result of  a denial, a provide r or suppli er is required to m ake a refund to a  beneficiary for amounts collected from t he beneficiary for the items or  services at issu e, then the  contractor must s end a copy of the adjust ed RA in the  following  situations:   1.  A nonpar ticipating physician not a ccepting a ssignment who, b ased on t he redetermination, now h as a refund obl igation unde r 1842( l)(1) of the Act;  2.  A nonpar ticipating suppli er not acc epting a ssignm ent who is de termined to ha ve a refund obli gation pursuant to 1 834(a)(18 ), due  to a denial unde r either 1834( a)(17)(B ) or 1834( j)(4) of the Act; or,  3.  A de nial based on 1879( h) of the Act of an assigned claim submitte d by a suppli er, where it is determined unde r 183 4(a)( 18) of the Act that the suppli er must ref und a ny payments (including deductibles and coinsu rance) collected from the  beneficiary.  NOTE:  For additional i nformation r egarding r efund r equirements, pl ease refer to IOM 100- 04 C hapter 30, sections 140 and 150.  C.  P aid Claim Appeals
(Medicare Claims Processing Manual)
NOTE:  For additional i nformation r egarding r efund r equirements, pl ease refer to IOM 100- 04 C hapter 30, sections 140 and 150.  C.  P aid Claim Appeals  If a contractor  receives a valid appeal r equest on a  claim th at was processed and pa id subs equent to the  filing of that appeal but pr ior to issu ance of the Medicare Redetermination Noti ce, the c ontractor  shall issue  an unfavorable decision l etter using the following template or som ething simila r to the  appellant:  (Start) EXHIBIT 1:      MONTH, DATE, YEAR   APPELLANT NAME                                       MEDICARE NUMBER OF  ADDRESS       BENEFICIARY:  CITY, STATE ZIP                  CONTACT INFORMATION:         If you have questions, write or call:         Contractor Name         Address         City, State Zip         Telephone number   RE:   <Include claim identifier or appeal number>   Dear <Appellant Name>:   This letter is to inform you of the decision on your Medicare appeal.  An appeal (also known as a redetermination) is a new and independent review of a claim.  You are receiving this letter because you requested a redetermination for <SERVICE(S)> on <DATE( S)>.  The redetermination decision is unfavorable because the service(s) in question has(have) already been paid by the MAC on <DATE>.  We have evaluated the information submitted and there do not appear to be any errors impacting the payment amount, which Model Redetermination  Unfavorable Decision for     Paid Claim  Appeal  is the maximum allowed by Medicare for this service.  As a result, we are issuing an unfavorable decision on your request for a redetermination on this claim.  If you disagree that the claim in question was previously processed for payment, and/or you otherwise disagree with this decision, you may appeal to a Qualified Independent Contractor.  You must file your appeal, in writing, within 180 days of receipt of t his letter, to the following address:  [INSERT QIC INFORMATION]   Sincerely,    NAME, TITLE  CONTRACTOR NAME   (End)  Exhibit 1      310.6 - Dismissals (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
Sincerely,    NAME, TITLE  CONTRACTOR NAME   (End)  Exhibit 1      310.6 - Dismissals (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Contractor Di smissal of  a Redetermination Request The contractor may dismiss a request for a redetermination unde r the following  circumst ances:  1. Request of a Party - A request for redetermination m ay be withd rawn at any time prior to the mailing or transmission of  the decision via  a secure Internet portal/application upon the  request of the party or parties filing the request for redetermination.  A par ty may request a dismiss al by filing a written noti ce of such request with the  contractor.  C ontracto rs may accept requests for withd rawal via facsimile  and/or  a secure Internet por tal/application, if  approved by CMS.  The dismiss al of a request for redetermination is binding unless vacated by the contractor or Q IC.  2. Dismiss al for Cause - The contractor may dismiss a redetermination re quest, either entirely or as to any stated issu e, under either of the followi ng circumst ances:  a) Where the party requesting a redetermination is not a  proper party, or  b) Where the party  requesting a r edetermination doe s not other wise have a right to a redetermination.  3. Failure to File Tim ely - When a request for redetermination is not f iled within the  time  limit required, and the  contractor did not f ind g ood c ause for failure to file timely, it should dismi ss the request.  4. Appointm ent of Representative is D efective  - When an indi vidua l who is a ttempting  to act a s a representative of an appellant who is not the  beneficiary submits an in compl ete appointm ent form and the  appointm ent is not correc ted within t he time  limit dis cussed above  in 270.1.6.B.1, the contractor  dismisse s the request.
(Medicare Claims Processing Manual)
NOTE:   If the appellant resubmits a n appeal r equest with a n appointm ent of representative form, the  contractor should c onsider the request as a duplica te and should not c ount the  resubmission a s additiona l workload. (See Pub. 100- 06, the  Medicare Financial Management M anual, Chapter 6.)  5. Party Failed to M ake A Va lid R equest - When the contractor determines the provider , suppli er, or State failed to make out a  valid re quest for redetermination th at subst antially compli es with 310.1.B.1. or 310.1.B.2.  A valid request may contain portions of the required information within the documents or attachments submitted with the appeal, so that 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.   6. Beneficiary Dies While the Request is P ending -  When a beneficiary or the beneficiarys representative files a request for redetermination, but the  beneficiary dies while  the request is pending , the contra ctor issu es a dismissal w hen all of the following cr iteria apply:  a) The beneficiary's surviving spouse  or estate has no re maining financial interest in the case.  In decidi ng this issu e, the contractor considers if the surviving spous e or estate remains lia ble for the services for which payment was denied or a Medicare contractor held the be neficiary liable for subsequent simila r services unde r the limita tion on liability provisions ba sed on the  denial of payment for services at issu e;    b) No othe r individua l or entity with a  financial interest in the  case  wish es to pur sue the appeal; a nd  c) No othe r party filed a valid and tim ely redetermination re quest.
(Medicare Claims Processing Manual)
c) No othe r party filed a valid and tim ely redetermination re quest.  7. There is not an initial determination (see 42 CFR 405.924 and 200.B above for actions that are initial determinations and 42 CFR 405.926 and 200.C above for actions that are not initial determinations).   B. Appeal Rights for Dismissals   Parties to the  redetermination ha ve the right to request a QIC review of the contractors dismissal of  a redetermination re quest if they believe the dismissa l is in correc t.  The  request for review must be  received by the  QIC within 60 calendar d ays after receipt of  the notice of dismiss al.  The date of receipt of the notice of dismissal is presumed to be 5 calendar days after the date of the notice of dismissal, unless there is evidence to the contrary. When the  QIC performs its review of  the dismiss al, it will d ecide  if the dismiss al was correct.  If it determines that the contractor in correctly dismiss ed the  redetermination, it will v acate  the dismissa l and remand the  case to the c ontractor  for a redetermination.  It is ma ndatory for the contractor to issue  a new redetermination d ecision  on any case remand ed by the  QIC.  The  new decision is c ounted in CRO WD on the  2590, 25 91 and 2592 a s appropriate as a "redetermination.  A QICs review of  a contracto rs dismissa l of a redetermination request is binding a nd not subj ect to a ny further review.  NOTE:  QICs shall not in clude the Important Information About  Your App eal Rights  insert when issuing a decision on r equests to r eview a contra ctors dismissal of a r equest for re determination.
(Medicare Claims Processing Manual)
NOTE:  QICs shall not in clude the Important Information About  Your App eal Rights  insert when issuing a decision on r equests to r eview a contra ctors dismissal of a r equest for re determination.   A party to the  redetermination m ay also re quest that the  contractor  vacate its dismiss al within 6 months of  the date of the mailing ( and/or  other transmission if  the contractor  is utiliz ing a CMS approved secure Internet portal/application) of the dismiss al noti ce if good a nd suffi cient caus e is establish ed.  If the contractor determines that th ere is good and suffi cient cause, the contractor vacat es its p rior dismiss al and issue s a redetermina tion.  F or the purposes of counting wor kload in CRO WD, this action s hould be  counted as a redetermination a nd not a  reopening.  See 310.6.3 Processing Requests to Vacate Dismissals for more information.   310.6.1 - Dismissal Letters  (Rev. 4380, Issued: 08 -30-19, Effective: 07 -08-19, Implementation: 10-  01-19)
(Medicare Claims Processing Manual)
310.6.1 - Dismissal Letters  (Rev. 4380, Issued: 08 -30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  The MAC sh all issue  in w riting and/or othe rwise transmit, a s not ed above , a notice of dismiss al to all parties to the appeal.  T he dismissa l noti ce includes the reason for the  dismissal.  The  dismiss al noti ce must in form parties that they may (1) request the MAC to v acate the  dismiss al, and ( 2) may request a Q IC reconside ration of the  dismissal.  T he dismiss al notic e is se nt to the  party requesting  the redetermination a t his/h er last known a ddress, and/or  other wise t ransmitte d as not ed above, as well as to his/h er representative and all oth er parties to the  appeal.  MACs who utilize  an approve d CMS secure Internet portal/application to receive  and pr ocess a ppeals m ay provide electronic dismiss al notices, if  the appeal request was received via  a secure portal/application.  MACs shall e nsure that a hard c opy dismissal notic e is se nt to oth er parti es to the appeal who do not ha ve access to the  secure  Internet portal/appli cation.  S ee 310.10 for additional  requirements related to noti ces se nt via secure portal/ appli cations.    MACs sh all include the following language, or som ething similar , in dismiss al letters (also see the mode l dismiss al letters in E xhibits 2 &3):  If you dis agree with this dismiss al, you have two options:   1. You may r equest that we vacate our dismissal.  W e will va cate our dismissal if you de monstrate  good and sufficient cause for <insert reason f or dismiss al>.  Your re quest to v acate  this dismiss al must be  received at our offi ce within 6 m onths of the date of receipt of this noti ce at the  addr ess noted above .
(Medicare Claims Processing Manual)
2. If you think we  have incorrectly dismiss ed your request (for example, you be lieve <insert reason (e.g., you did file your request on t ime, you w ere a proper party, the MAC  did issue  an initia l determination on the  claim)>), you m ay request a reconside ration of  the dismissal by a Qualified Independent Contractor (QIC).  Your request must be received by the QIC at the address below within 60 days of receipt of this letter.  In your request, please explain why you believe the dismissal was incorrect.  The QIC will not consider any evidence for establishing coverage of the claims(s) being appealed.  Their examination will be limited to whether or not the dismissal was appropriate.  Please send your request to:   Insert QIC Address   Incomplete Requests -  The requirements for written requests for redetermination are found in 310.1.B.2.  NOTE:  Beneficiary requests should not be considered incomplete, see 310.1.B.1 and 310.1.B.3.  MACs must handle and count incomplete redetermination requests as dismissals.  If a party submits an incomplete request for redetermination and the MAC issues a dismissal notice, the party may request the dismissal be vacated, the party may appeal the dismissal, or the party may refile their request if any time remains in the filing perio d (i.e., 120 days from receipt of the initial determination).  When a request is refiled that meets the requirements, the previous dismissal is vacated and reopened.  MACs must notify parties of their options in the dismissal notice.  Please see the model dismissal notice for an incomplete request in 310.6.2.   310.6.2 - Model Dism issal Notices                                                                                      (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10 - 01-19)   NOTE:  This is a model letter and may need to be adjusted to include additional verbiage/instructions if a MAC has received approval to receive appeal requests via a secure Internet portal/application.   (Start) EXHIBIT 2:     Model Redetermination Dismissal Notice For Incomplete or Invalid Request      MONTH, DATE, YEAR
(Medicare Claims Processing Manual)
(Start) EXHIBIT 2:     Model Redetermination Dismissal Notice For Incomplete or Invalid Request      MONTH, DATE, YEAR   APPELLANT NAME                                                MEDICARE NUMBER OF  ADDRESS         BENEFICIARY:  CITY, STATE ZIP   CONTACT INFORMATION:  If you have questions, write or  call:  MAC Name  Address  City, State Zip  Telephone number   RE:   <Include claim identifier or appeal number>   Dear <Appellants Name>:  This letter is in response to your appeal request (also known as a redetermination) that was received in our office on <INSERT DATE>.  The redetermination was requested for the following dates of service <INSERT DATE(S)>).  Your redetermination request has  been dismissed because it did not form a valid request for redetermination.  In order to process a redetermination request, we need the following item(s) to be addressed:   <INSERT ALL APPLICABLE INFORMATION>:   Missing Information:    The beneficiarys name;    The Medicare number of the beneficiary;    The specific service(s) and/or item(s) for which the redetermination is being requested and the specific date(s) of service;    The name of the person filing the redetermination request.    Invalid Request:    The requestor is not a proper party;    Defective Appointment of Representation (AOR) <for non- beneficiary submitted claims only>;   No initial determination on the claim(s) appealed; or    Beneficiary is deceased with no remaining party or appointed representative with financial interest.     Your request was determined to be invalid as explained above and therefore has been dismissed.  You may file your request again if it has been 120 days or less since the date of receipt of the initial determination notice.  When you file your request, plea se make sure you have addressed all of the above listed items and send your request to our office at the address noted above.   If you disagree with this dismissal, you have two additional options:   1. You may request that we vacate our dismissal.  We will vacate our dismissal if you demonstrate that you have good and sufficient cause for failing to submit a valid request.  Your request to vacate this dismissal must be received at the address above within 6 months of the date of receipt this notice.
(Medicare Claims Processing Manual)
2. If you think we have incorrectly dismissed your request (that is, you believe you did address all of the above listed items in your request), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC).  Your request must be received by the QIC at the address below within 60 days of receipt of this letter.  In your request, please explain why you believe the dismissal was incorrect.  The QIC will not consider any evidence for establishing coverage of the claim(s) being  appealed.  Their examination will be limited to whether or not the dismissal was appropriate.  Please send your request to:   <INSERT QIC ADDRESS>   Sincerely.    NAME, TITLE  MAC NAME        (End) EXHIBIT 2           (Start) EXHIBIT 3:       MONTH, DATE, YEAR   APPELLANT NAME                                                   MEDICARE NUMBER OF  ADDRESS        BENEFICIARY:  CITY, STATE ZIP   CONTACT INFORMATION:  If you have questions, write or  call:  MAC Name  Address  City, State Zip  Telephone number   RE:  <Include claim identifier or appeal number>   Dear <Appellants Name>:   This letter is in response to your appeal request (also known as a redetermination) that was received in our office on <INSERT DATE>.  The redetermination was requested for dates of service <INSERT DATE(S)>.  The initial determination for the items/service s in dispute was issued on <INSERT DATE OF RA/MSN>.   Your redetermination request has been dismissed because the date(s) of service in question is/are past the time limit to file a request for a redetermination.  A redetermination request must be received in our office within 120 days of the date of receipt of the initial determination date  on the Medicare Remittance Advice or the Medicare Summary Notice.  The date of receipt of the initial determination is presumed to be 5 days after the date of the notice unless there is evidence to the contrary.  Model Redetermination Dismissal Notice For An Untimely Appeal    When we receive a request that has been filed late, we consider whether the appellant had good cause for filing late.  In special circumstances, we may allow additional time to file.  In this case, we did not find good cause for filing your request late.   If you disagree with this dismissal, you have two options:
(Medicare Claims Processing Manual)
If you disagree with this dismissal, you have two options:   1. You may request that we vacate our dismissal.  We will vacate our dismissal if you demonstrate good and sufficient cause for filing late.  Your request to vacate this dismissal must be received at the address above within 6 months of the date of receipt of  this notice.   2.  If you think we have incorrectly dismissed your request (for example, you believe you did file your request on time), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC).  Your request must be received by the QI C at the address below within 60 days of receipt of this letter.  In your request, please explain why you believe the dismissal was incorrect.  Please note that the QIC will not consider any evidence for establishing coverage of the claim(s) being appealed .  Their examination will be limited to whether or not the dismissal was appropriate.  Please send your request to:    <INSERT QIC ADDRESS>    Sincerely.     NAME, TITLE   MAC NAME       (End) Exhibit 3   310.6.3  Processing Requests to Vacate Dismissals (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  If a party submits a request to vacate the dismissal, and the request contains sufficient evidence or other documentation that supports a finding of good cause for late filing, the MAC makes a favorable good cause determination.  Where a finding for good cause is made, the MAC shall document the reason for that finding in the appeal decision letter, the appeal c ase file, or both.  Once it makes a favorable good cause determination, it considers the appeal to be timely filed, vacates its prior dismissal action, and performs a redetermination.  For the purposes of counting workload in CROWD and in the MAS, a determ ination to vacate a dismissal should be counted as a redetermination and not a reopening.
(Medicare Claims Processing Manual)
If the MAC does not find good cause to vacate the dismissal, the dismissal remains in effect.  The MAC issues a letter (not a dismissal letter) explaining that good cause has not been established and the dismissal cannot be vacated.  Although the appellant  may not appeal a MACs finding that good cause was not established when the appellant requested that the MAC vacate its dismissal, the appellant maintains their right to request a QIC review of the MACs dismissal action.  However, requests for QIC review  of a MACs dismissal action must be received by the QIC within 60 days of the date of receipt of the dismissal notice.  For purposes of counting workload in CROWD and in the MAS, a MACs determination not to vacate a dismissal action is counted as an inquiry, not as a dismissal action.   If an appellant requests that the MAC vacate the dismissal action, and the MAC determines that that it cannot vacate the dismissal, the MAC sends a letter notifying the appellant.  The MAC shall not issue a second dismissal notice to the appellant since a dismissal should only be issued in response to an appeal request.  A request to vacate a dismissal is not a request for an appeal.   If the contractor determines that the request to vacate the dismissal of the redetermination request does not provide good and sufficient cause to vacate, the contractor shall respond with a letter that addresses why the request to vacate does not meet the criteria for good cause.  Any evidence or information not previously submitted with the redetermination request that is submitted with the request to vacate the dismissal shall be addressed by the contractor in their letter.  The contractor must explain i n clear language why all evidence and information submitted, including what was sent with the request to vacate the dismissal, does not meet the requirement necessary to vacate the dismissal.   310.7 - Medicare Redetermination Notice (For Partly or Fully Unfavorable Redeterminations)    (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  The contractor uses the following Medicare Redetermination Noti ce (MRN) format or som ething simila r and st andard language paragraphs whe ther the redetermination noti ce is delivered via har d copy mail or via a CMS-approved por tal/application.