evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Any additiona l evidence submitte d by the appellant.  *If accessible  by internet, the  MAC that issu ed the  redetermination d ecision may  enter into a  joint operating a greement with the  QIC to pr ovide a list instead of  actual copies.  Assembly Instructions:   The MAC us es an appropriate file/folder/envelope which will c ontain necessary documents in pr oper order, if the case file is not t ransmitte d electronically.   For combine d requests filed by a beneficiary, the MAC  keeps the  documents relating to t reatment from e ach pr ovider , physician, or supplier together.  It separates the documents relating to each p rovider, physician or suppli er by a blank sheet of  paper;   For combine d requests filed by a provider , physician, or othe r suppli er, the MAC keeps the  documents relating to each beneficiary together and or ganized   alphabetically by beneficiary last name.  It separat es the documents relating to each b eneficiary by a blank she et of p aper.  It provides a complete set of procedural doc uments for each be neficiary; and   The MAC  groups pr ocedura l documents toge ther in chronological o rder and groups m edical doc uments together in chronological order.  Recon sideration Case  Transmittal Form  The Reconside ration C ase Transmitta l Form documents the  claim in formation a nd the  date of the redetermination.  It also ide ntifies the MAC t hat made the redetermination a nd the  QIC with jurisdiction f or the reconsid eration.  The  summ ary sheet should be  placed on top of  the doc uments in the case  file.  The  QIC will p rovide  a Reconside ration C ase Transmitta l Form for use  in the  JOA.  320.6 - Forwarding QIC Case Files (Rev.  4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)
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320.6 - Forwarding QIC Case Files (Rev.  4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  MACs sh all send/transmit the  case  file within 7 ca lendar days of the date of the QIC's request.  The  date of QIC's request is d efined as the date the phone call is ma de (if a message is left, it is d efined as the date the message was left) or the date of the email request.  The  case files must be  sent either by an electronic means agreed upon in the  joint opera ting agreem ent or by a courier service so tha t the case file is received by the QIC before or on the  8th cal endar day after its re quest.  T he MAC c ounts the costs asso ciated with sending c ase fil es in the  Contra ctor Administrative  Budge t and Financ ial Manag ement (CAFM) code designat ed for pr eparing/transf erring c ase fil es to the  QIC.  320.7 - QIC Jurisdictions  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  A.  Part A  QIC J urisdictions  The Part A Q IC jurisdictions ar e as follows:
(Medicare Claims Processing Manual)
A.  Part A  QIC J urisdictions  The Part A Q IC jurisdictions ar e as follows:     Jurisdiction  Normal States  Exceptions  Part A E ast QIC jurisdiction Alabama, Ar kansas, Colorado, C onnectic ut, Delaware, Florida, Georgia, L ouisiana, M aine, Maryland, M ississippi, Massachusetts, N ew Hampshir e, New Mex ico, New Jersey, New York, Texas, O klahoma, N orth Carolina, P ennsylvania, Puerto Ri co, Rhode I sland, South C arolina, T ennessee, Vermont, Virgin I slands, Virginia, W est Virginia, and W ashington DC  and Mutua l of Omaha claims where the service was rendered in one  of the above  listed States. Chain Providers (including ESRD)  the St ate where the MAC  processed the  claim.  F or providers who pr eviously submitte d claims to Mutua l of Omaha (currently processe d by WPS), the jurisdiction c ontinue s to be  the St ate where the service was rendered.  Indian  Health Services claims Nationwide  Foreign claims- Eastern Mexico, Canadian Provinces of  New Brunswick, Newfoundl and, Nova  Scotia, Quebec, and Prince Edw ard Island  Rural Health Clinic claims Nationwide Part A West QIC jurisdiction  Alaska, Am erican Samo a, Arizona, California, Guam, Hawaii, Idaho, I llinois, Indiana, Iowa, Kansas, Kentucky , Michigan, Minnesota, M issouri, Montana, N ebraska, Nevada, North Da kota, Northern M ariana Islands, Ohio, Or egon, South Dakota, Utah, Washington, Wisconsin and Wyoming and Mutua l of Omaha claims wh ere the service was rendered in on e of the above  liste d States.  Chain Providers (including ESRD) - the St ate where the MAC processed the  claim.  F or providers who pr eviously submitte d claims to Mutu al of Omaha (currently processe d by WPS), the jurisdiction c ontinue s to be  the St ate where the service was rendered.  Foreign claims- Western Mexico, Canadian Provinces of  Ontario, Saskatchewan, Alber ta, Manitoba , British C olumbi a, Vancouve r, and Yukon Territories.   B.  Part B  and DME QIC Jurisdictions
(Medicare Claims Processing Manual)
Foreign claims- Western Mexico, Canadian Provinces of  Ontario, Saskatchewan, Alber ta, Manitoba , British C olumbi a, Vancouve r, and Yukon Territories.   B.  Part B  and DME QIC Jurisdictions  There is one  DME Q IC jurisdiction assigned to pr ocess a ll reconsiderations of  DME  claims for all state s and t erritori es.  Th ere are two Q IC jurisdictions f or Part B claims, a  North and a South jur isdiction. Refer to the t able below.    Jurisdiction Normal States Exceptions  Part B South Jurisdiction  Alabama, Ar kansas, Colorado, Florida, Georgia, L ouisiana, Mississ ippi, New Mex ico, North C arolina, Oklahoma, Pue rto Ri co, South C arolina, Tennessee, T exas, Virginia, West Virginia, Virgin Islands.  Note: Railroad Retirement Board recon siderations are also i ncluded in this workload jurisdiction. Part B North Jurisdiction  Alaska, Am erican Samo a, Arizona, C alifornia,  Connectic ut, D elaware, Guam, Haw aii, Idaho, Illinois, I ndiana, Iowa, Kansas, Kentucky , Maine, Maryland, M assachusetts, Michigan, M innesota, Missouri, M ontana, Nebraska, Nevada, New Hampshir e, New Jersey, New York, North Da kota, Northern M ariana Islands, Ohio, Or egon, Pennsylvania, Rhode  Island, South Da kota, Utah, V ermont, Washington, Washington DC, Wisconsin and Wyoming.   DME QIC Jurisdiction  All states and territories    320.8 - Tracking Cases  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)
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DME QIC Jurisdiction  All states and territories    320.8 - Tracking Cases  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  Contracto rs shall track all incoming requests for c ase fil es from the  QICs.  The contractor shall keep a  record of the date of the request, the  format of the request (e.g., telephone , emails, electronic) the date the case file was forwarded to the QIC, and the  means of  forwarding (e.g. Fed Ex Same Day, Fed Ex overnight, U PS 2 da y).  If a courier service is used, the  contractor shall utili ze the courier services tracki ng mechanism to k eep a  record of the date of receipt at the Q IC.  Contracto rs shall track all mis filed reconsid eration re quests to e nsure receipt at  the proper QIC.  The QIC will s end the  MAC  or DME MAC  an acknowl edgement of receipt of  any misfiled   requests.  C ontracto rs shall keep a record of the date of receipt of  the misfiled request, the  date it was forwarded to the  QIC, the means of  forwarding, and the  date of the QICs acknowl edgement.  Contracto rs shall track all requests from the  QIC for effectuation.  The  contractor  shall ma ke a recor d of the date of receipt of  the QICs request for effectuation a nd confirm receipt of  the effectuation noti ce with the  QIC.  The  contractor  shall also track the  date of effectuation ( i.e., issue  payment).  320.9 - Effectuation of Reconsiderations  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)
(Medicare Claims Processing Manual)
320.9 - Effectuation of Reconsiderations  (Rev. 4380, Issued: 08- 30-19, Effective: 07 -08-19, Implementation: 10-  01-19)  In many cases, the  QIC's decision will re quire an effectuation action on the  MACs p art.  The  MAC  does not e ffectuate based on corresponde nce from a ny party of the rec onside ration.  It takes an effectuation a ction only in respons e to a formal decision a nd R econsid eration Effectuation Noti ce from the  QIC.  "Effectu ate" means f or the MAC  to adjust the claim and issue  a payment or to change liability.  If the QIC's decision is fa vorable to the  appellant and gives a specific amount to be  paid, the  MAC  effectuates within 30 cal endar days of the date of receipt of the e ffectuation noti ce from the  QIC.  NOTE:  CMS does not a nticipate that QICs will sp ecify an amount to be  paid in reconside ration noti ces.  If the decision is fa vorable, but the  payment amo unt must be  comput ed or r ecomput ed, it effectuat es the decision w ithin 30 da ys aft er the payment amount is de termined.  The  amount must be  comput ed as soon a s possibl e, but no l ater than 30 cal endar days after the date of receipt of  the QIC's effectuation  notice.  The  receipt of  effectuation in formation sha ll be reported to the a ppropriate QIC.  If the QICs decision is unfa vorabl e, but the re is a change  in liability, the  MAC e ffectuat es within 30 c alendar da ys of receipt of the  QICs effectuation noti ce.  330 - Administrative Law Judge (ALJ) Hearing or Attorney Adjudicator Review at the Office of Medicare Hearings and Appeals (OMHA) - The T hird Level of Appeal (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
A party to a Q IC reconside ration m ay request a hearing before an ALJ if the party files a written request for an ALJ hearing within 60 da ys after receipt of  the notice of the QICs recon sideration a nd the a mount in c ontroversy requirement is me t*.  A  party who f iles a time ly appeal b efore a QIC and whose  appeal continues to be  pending before a QIC at the end of the QICs decision -making tim eframe has a right to a  hearing before an ALJ if the party files a written request with the  QIC to e scalate the appeal to the  ALJ level after the adjudication per iod expires and the  QIC does not issue  a final action with in 5 da ys of receivi ng the request for escalation.  A par ty wishing to escalate an appeal must a lso m eet the  amount in c ontroversy requirement*.  A p arty to a Q ICs dismissa l of a request for reconside ration ha s a right to ha ve   the dismiss al reviewed by an ALJ or attorney adjudicator if the party meets the  amount in controversy requirement*.  *See 250 for A IC information. T he current amount in c ontrove rsy requirements can be  found on the  CMS.gov c laims app eals webpage:  http://www.cms.gov/Medicare/Appeals -and-Grievances/OrgMedFFSAppeals/Downloads/AppealsProcessFlowchart -FFS.pdf   330.1 - Requests for an ALJ Hearing (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Where P arties File Requests
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330.1 - Requests for an ALJ Hearing (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  A. Where P arties File Requests  To re ceive an ALJ hearing, a party to the  QICs reconsideration must file a written request for an A LJ hearing with the  entity specified in the  QICs reconside ration.  The  appellant must also send a copy of the request for hearing to the  other parties.  Fa ilure to do so will toll the  ALJs 90- day adjudi cation d eadline  until all parties to the  QIC reconsideration r eceive  notice of the requested ALJ hearing.  Also, if  the request for hearing is timely filed with a n entity other than the  entity specified in the  QICs reconsideration, the  ALJs deadline  for decidi ng the appeal b egins on the da te the entity specified in the  QICs reconside ration ( i.e., the  appropriate OMHA o ffice) receives the request for hearing.  The QICs will sp ecify the appropriate OMHA office as the filing location f or ALJ hearing requests.  B.  Timely Filing Requirements  A party must f ile an ALJ request within 60 da ys of the date of their receipt of  the QICs decision. I t is p resumed tha t the appellant received the  QICs decision within f ive days of the date of the Q ICs decision, unl ess there is a reasonable show ing by the appellant to the  contrary.  C.  Co ntent of the Request  The request for an ALJ hearing must be  made in writing.  The  request must include all of the followin g:  1.   The  name, address, and Medicare numbe r of the beneficiary whose  claim is being appealed,  2.   The  name and address of the appellant, whe n the appellant is not the  beneficiary,  3.   The  name and address of the designated representative, if any,  4.   The  document control number assigned to the  appeal b y the QIC, if any,    5.   The  dates of service,
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3.   The  name and address of the designated representative, if any,  4.   The  document control number assigned to the  appeal b y the QIC, if any,    5.   The  dates of service,  6.   The  reasons the  appellant disagrees with the  QICs reconside ration or  othe r determination be ing appealed, and  7.   A st atement of any additiona l evidence to be  submitte d and the  date it will be  submitte d.  For the conve nience of parties, OMHA p rovides forms th at may be used to re quest a Medicare ALJ hearing.  It is not n ecessa ry, however, that this f orm be  used to make a written request.   The request for hearing form OMHA -100:     https://www.hhs.gov/sites/default/files/OMHA -100.pdf                                    In addition, the form OMHA 100A is used as an attachment to form OMHA 100 to identify multiple beneficiaries or enrollees associated with a single request for an ALJ hearing or a review of dismissal.  The direct link to form OMHA -100A:    https://www.hhs.gov/sites/default/files/OMHA -100A -Multiple -Claim-Attachment.pdf    The link to OMHAs webpage containing all forms:    https://www.hhs.gov/about/agencies/omha/filing- an-appeal/forms/index.html   To request that OMHA make a decision  without a hearing based only on the information thats in the appeal record, an appellant must submit the information required for an ALJ hearing request and one of these:    The Waiver of Right to an Administrative Law Judge (ALJ) Hearing form (Form OMHA -104) available at https://www.hhs.gov/sites/default/files/OMHA -104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf ; or   A written request stating that you dont wish to appear before an ALJ at a hearing (including a hearing held by phone or video- teleconference), and explaining why you decided to waive the hearing.
(Medicare Claims Processing Manual)
 A written request stating that you dont wish to appear before an ALJ at a hearing (including a hearing held by phone or video- teleconference), and explaining why you decided to waive the hearing.   Even if a waiver of hearing is requested, a hearing may still be held by an ALJ if the other parties in the case dont also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide the case.       330.2 - Forwarding Requests to OMHA  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19) Requests for ALJ hearings are to be  filed with the  OMHA office at the address sp ecified in the  QICs reconside ration noti ce.  How ever, ther e may be times when par ties incorrectly file requests for hearings with e ither the MAC  or QIC.  When a MAC  receives such a misfiled request, it f orwards the  misfiled request to the  OMHA Ce ntral Do cketing lo cation within 30 calendar days of receipt.  All MACs sh all ma intain a reco rd of these cases.  Requests for all A LJ hearings must be  filed at the  follo wing loc ation:    OMHA Centraliz ed Do cketing 200 Public  Squar e, Suite  1260 Cleveland, OH 44114- 2316  330.3 - Review and Effectu ation of OMHA  Decisions (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
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330.3 - Review and Effectu ation of OMHA  Decisions (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The Administrative  QIC (AdQI C) is the  clearingh ouse for all Original Me dicare (Part A and Part B)  claim c ase fil es and decisions from the  OMHA fi eld offi ces as w ell as any  decisions and c ase fil es from the  Appe als Counc il.  T he AdQI C reviews OMHA dec isions for  possible  agency r eferral to the  App eals C ounc il.  For Appe als C ounc il decisions and for OMHA  decisions w hen no age ncy referral is plann ed, the  AdQI C will send the  MAC an e ffectuat ion notice, a c opy of the  decision, and a sum mary of the  asso ciated claims from the  MAS.  The MAC only e ffectuates bas ed on doc umentation r eceived from the  AdQI C; the MAC does not e ffectuate  based on c orrespon dence from a ny party  to the  ALJ hearing or attorney adjudicator review.  " Effectuat e" means for t he MAC to issue  a paym ent or change liability.   In the  event that the  MACs c laims pa yment review finds the  OMHA or Appe als C ounc il decision to be  inconsist ent or ina ccurate in c omparison to c laims history  the MAC may r equest assistan ce from the  AdQ IC in seeking c larifi cation from OMHA  or the Appeals C ounc il.  330.4 - Effectuation Time Limits & Responsibilities (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06 -13-19)    In most c ases, OMHA will:  ( 1) issue  a decision ba sed on the  request for an ALJ hearing or review ; or ( 2) issue  an order of dismissal of the appellants request for ALJ hearing or review ; or (3) remand the  case to the  QIC.
(Medicare Claims Processing Manual)
If OMHAs  decision is partially  or w holly fa vorable  to the  appellant and gi ves a sp ecific  amount to be  paid, the  MAC e ffectuat es within 30 c alendar da ys of re ceipt of the  effectuation notice from the  AdQI C.  The MAC must a cknowledge receipt of the  AdQIC effectuation pe r the JOA with the  AdQ IC.  If the decision is partiall y or w holly fa vorable  but the  amount must be  computed by the MAC, it e ffectuat es the decision w ithin 30 da ys aft er it comput es the amount to be  paid to the appellant.  T he amount must be  comput ed as s oon as possibl e, but no la ter than w ithin 30 calendar da ys of the  date of receipt of the  effectuation noti ce from the  AdQI C.  For e ffectuation of decisions that in volve overpayments or unde rpayments where the limitation on r ecoupm ent provision  appli es (Section 935 of MMA ), refer to I OM Pub. 100-06, C hapter 3, 200 for furthe r instru ction.  If clarification from the  AdQIC is necessary, the MAC  consider s the date of the clarification the final determination f or purposes of effectuation.  If clarification is n eeded from the provider /physician/suppli er (e.g., splitting c harges), the MAC  requests clarification a s soon a s possible  and comput es the amount pa yable within 30 calendar days after the receipt of  the necessa ry clarification.  The MAC  conside rs the date of receipt of  the clarification a s the d ate of the final determination f or purposes of effectuation.  330.5 - Duplicate OMHA  Decisions  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
(Medicare Claims Processing Manual)
330.5 - Duplicate OMHA  Decisions  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If the MAC  becom es aware of a dupli cate decision from OMHA on the  same case, it must bring this to the  attention of  the AdQIC imme diately.  In these cases the AdQIC will ta ke the necessa ry steps to re solve  the issue.  330.6 - Payment of Interest on OMHA  Decision s (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  For guidance on how to make payment of interest subsequent to a  decision from OMHA, ref er to chapter 3 of  the Medicare Financial Management M anual, Pub. 100- 06 (http://www.c ms.gov/ma nuals/dow nloads/ fin106c 03.pdf ).    340 - Departmental Appeals Board - Appeals Council - The Fourth L evel of Appeal (Rev. 4278., Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  The level of administra tive review available to parties after the ALJ hearing decision, OMHA attorney adjudicator review, or  dismiss al order has been issu ed, bu t before judicial review is available, is App eals Counc il review.
(Medicare Claims Processing Manual)
A party  to an  ALJ hearing or an OMHA attorney adjudicator review, may request review by the App eals C ounc il within 60 da ys aft er receipt of the  notice of OMHA s decision or dismissal.  If a party requests the  App eals Counc il to re view an ALJs or attorney adjudicators decision, the  App eals C ouncil may c onduc t a de no vo review of the decision a nd may a dopt, modi fy, or reverse the ALJs or attorney adjudicators d ecision, or  remand the  case  to an ALJ or attorney adjudicator  for further proceedings.  See , in g eneral 42 C FR 405.1108.  The Appeals C ounc il will dismiss a r equest for rev iew when a party  does not ha ve a right to Appeals C ounc il review.  When a party requests th at the App eals C ounc il review an ALJs or attorney adjudicator's dismiss al, the App eals C ounc il ma y deny review or remand the  case  to an ALJ or attorney adjudicator f or further proceedings.  The App eals Counc il may  also dismiss a r equest for a hearing for any r eason the  ALJ or attorney adjudicator c ould ha ve dismiss ed the r equest for hearing.  In addition, the  App eals C ounc il will d ecide cases that are escalated from the  OMHA level without a n ALJ or attorney adjudicator decision or  dismiss al.  See 42 CFR 405.1108(d) .  The Appe als C ounc il may  also d ecide  on its ow n motion to r eview a decision or dismissal issu ed by an A LJ or attorney adjudicator w ithin 60 da ys aft er the date of the decisi on or dismissal.   340.1 - Recommending Agency Referral of OMHA Decisions or Dismissals  (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
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340.1 - Recommending Agency Referral of OMHA Decisions or Dismissals  (Rev. 4278., Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  CMS may  refer a case to the App eals C ounc il for it to c onside r unde r its o wn motion r eview authority w ithin 60 da ys after the date of the  ALJ hearing or attorney adjudicator decision or dismissal.  T his is know n as an agency referral.  The Appeals C ounc il may  adopt, modif y, or reverse  OMHA s decision, may r emand the  case to an A LJ or attorney adjudicator  for furth er pro ceedings, or may dismiss an ag ency referral re quest.  For OMHA  decisions issu ed by O MHA AL Js and attorney adjudicators, the AdQI C will be  responsible  for rev iewing A LJ and attorney adjudicator decisions and de termining w hether an ag ency referral is appropriat e.  During the effectuation of an A LJ or attorney adjudicator decision, if the  MACs m edical director disagr ees w ith the d ecision and w ishes to dis cuss the  decision for pot ential r eferral to the App eals C ounc il, the me dical dir ector shall c ontact the AdQI C.  340.2 - Effectuation of Appeals Council Orders and Decisions  (Rev. 985, Issued:  06 -16-06; Effective/Implementation Dates:  07 -17-06)    When a MAC receives an effectuation notice from the AdQIC  regarding an Appeals Council decision that requires effectuation, it initiates effectuation within 30 days of its receipt of the effectuation notice, and completes effectuation within 60 days.  Any questions regarding effectuation should be directed to the AdQIC for guidance.   340.3 - Requests for Case Files         (Rev. 4278, Issued: 04 -12-19, Effective: 06- 13-19, Implementation: 06- 13-19)