Source: https://www.federalregister.gov/documents/2005/06/30/05-12982/medicare-program-changes-to-the-medicare-claims-appeal-procedures-correcting-amendment-to-an-interim
Timestamp: 2018-02-21 22:10:16
Document Index: 193769720

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Federal Register :: Medicare Program; Changes to the Medicare Claims Appeal Procedures: Correcting Amendment to an Interim Final Rule
A Rule by the Centers for Medicare & Medicaid Services on 06/30/2005
This correcting amendment is effective July 1, 2005.
70 FR 37700
37700-37705 (6 pages)
05-12982
PART 401—[CORRECTED]
https://www.federalregister.gov/d/05-12982 https://www.federalregister.gov/d/05-12982
Correcting amendment to an interim final rule.
This amendment corrects technical errors in the interim final rule with comment period that appeared in the Federal Register, entitled “Medicare Program: Changes to the Medicare Claims Appeal Procedures.”
We have identified technical errors and omissions that appeared in the interim final rule with comment period entitled “Medicare Program: Changes to the Medicare Claims Appeal Procedures.” (FR Doc. 05-4062) (See 70 FR 11420, March 8, 2005.) In this correcting amendment, we are correcting these technical errors and omissions.
On page 11436 of the preamble, we identified decisions regarding the timely submission of claims as not being initial determinations. We attempted to convey that this was true whether a provider or supplier failed to submit a timely claim for its own purposes or at the request of a beneficiary or the beneficiary's Start Printed Page 37701subrogee. However, we inadvertently omitted the word “timely” from our discussion of the submission of a claim by a provider or supplier for its own purposes.
On pages 11456 through 11457, we discussed the requirement that administrative law judge (ALJ) hearings be conducted by videoteleconferencing (VTC) (if the technology is available and there are no special or extraordinary circumstances that would make a VTC hearing inappropriate). We also indicated, however, that a party could request an in-person hearing that the ALJ, with the concurrence of the Managing Field Office ALJ, would grant upon a finding of good cause.
The interim final rule generally requires that an ALJ conduct a hearing and render a decision within 90 days from the date the request for hearing is received. However, if the ALJ grants a party an in-person hearing upon a finding of good cause, then that 90-day time frame requirement is waived.
In the interim final rule, we inadvertently stated that the request by a party for an in-person hearing would result in a waiver of the 90-day hearing and decision making time frame requirement. Therefore, we clarify that a request by a party for an in-person hearing does not relieve the ALJ of the 90-day hearing and decision making time frame requirement. Rather, waiver of the 90-day hearing and decision making time frame requirement results only when an ALJ grants the request for an in-person hearing. In addition, we clarify that any party, not just the appellant, can object to the type of hearing scheduled by an ALJ and request an in-person hearing.
In § 405.1012(a), we provide that CMS or its contractor, including a qualified independent contractor (QIC), may be a party to an ALJ hearing. On page 11461 of the preamble, we say that it is appropriate “to permit discovery when an ALJ hearing is adversarial (that is, whenever CMS or its contractor is a party to an ALJ hearing).” Later, in the same response on pages 11461 through 11462, in the second column, when discussing how and when the discovery provisions apply, we refer only to CMS electing to participate as a party. To correct the inconsistency in the discussion of this issue, we clarify here our intention to permit limited discovery not only when CMS elects to participate as a party to a hearing, but also when a CMS contractor elects to participate as a party to an ALJ hearing. We also make a similar correction to the text of the regulations at § 405.1016(d) and § 405.1037(a)(1).
1. On page 11436, in the first column, line 17, in the first full paragraph, we inserted the word “timely” after the phrase “submit a claim”.
2. In the third column of page 11456, in line 2 of the first full response, the word “appellant” is replaced with the word “party”.
3. On page 11457, in the first column, on line 1, the word “granted” is inserted before “request”.
4. On page 11461, in the second column, on line 35, in the first full response, the words “or its contractor” are inserted after “CMS”.
5. On page 11461, in the third column, in lines 25, 30, 57, 61, 66, and 68 the words “or its contractor” are inserted after “CMS”.
6. On page 11462, in the first column, in lines 3, 4, 47, and 53 the words “or its contractor” are inserted after “CMS”.
In the interim final rule, we made technical omissions in § 405.926, § 405.980, § 405.990, § 405.1020, and § 405.1102. We also made typographical and editing errors in § 405.980, § 405.986, § 405.990, § 405.1016, § 405.1018, § 405.1020, § 405.1037, § 405.1042, § 405.1052, § 405.1104, § 405.1112, and § 405.1136. We are reflecting these corrections in section D of this correcting amendment.
Section 405.912 contains the new provisions regarding assignment of appeal rights. In § 405.912(g) and § 405.912(g)(1), we incorrectly referred to the “assignee” as the “assignor” and vice versa. We are reflecting these corrections in section D of this correcting amendment.
As we indicated in section A of this correcting amendment, we inadvertently omitted the word “timely” when we stated that determinations regarding whether a provider or supplier submitted a claim timely either for its own purposes or at the request of a beneficiary or the beneficiary's subrogee are not initial determinations. The corresponding correction to the regulation text at § 405.926(n) is made in section D of this correcting amendment.
In the interim final rule, we state that submitting evidence after an appeal is filed may result in a 14-day extension of the decision-making time frame. Although this 14-day extension applies automatically, adjudicators are not required to extend the decision-making time frame by the full 14 days. In the regulation text, we intended to convey this point in § 405.946(b), § 405.950 and § 405.970 by stating that the decision-making time frame is extended “by up to 14 days” each time evidence is submitted after an appeal is filed. At § 405.946(b) and § 405.950(b)(3), however, we inadvertently left out the words “up to”. We have corrected this omission in section D of this correcting amendment.
Paragraph (a) of § 405.970 states that the QIC will transmit to the parties a written notice of “(1) The reconsideration; (2) Its inability to complete its review within 60 days in accordance with paragraphs (c) through (e) of this section; or (3) Dismissal.” Paragraph (c)(2), however, states that notice of the QIC's inability to complete review is mailed only to the appellant. For reasons of consistency and to decrease ambiguity, we correct this error in section D of the correcting amendment.
On page 11450 of the preamble, we stated the general rule that a remedial action taken by an appeals adjudicator to change a final determination or decision is a reopening “even though the determination or decision may have been correct based upon the evidence of record.” In the corresponding regulation text at § 405.980(a)(1), our use of the word “was”, rather than the phrase “may have been” seems to contradict the preamble language. To ensure that the preamble and regulation text are consistent, this error is corrected in section D of this correcting amendment.
In paragraph (a)(4) of § 405.980, we inadvertently stated that adjudicators are prohibited from reopening a claim at issue until all appeal rights are exhausted. We meant to state that adjudicators are prohibited from reopening issues within a claim, if those issues are on appeal. We correct this statement in section D of this correcting amendment.
Also in § 405.980, in paragraphs (d)(2) and (e)(2), we indicated that only an ALJ can reopen an ALJ decision. These provisions, as they appear in the interim final rule, seem to contradict the policy established earlier at § 405.980(a)(iv), which states that the MAC may reopen its decision, as well as any hearing decision issued by an ALJ. This inconsistency is corrected in section D of this rule.
The good cause standard for reopening initial determinations is defined in § 405.986. As a result of an editing error, we included paragraph (d), a provision that identifies a type of determination that is not a reopening. This provision is actually part of paragraph (a)(6) of § 405.980. This editing error is corrected in section D by Start Printed Page 37702deleting paragraph (d) from § 405.986 and inserting it into § 405.980(a)(6).
In § 405.1014(b)(2), we stated that the proper filing location for ALJ hearing requests is with the entity specified in the qualified independent contractor's reconsideration. However, in § 405.1046(d), we incorrectly referred to the ALJ hearing office as the proper filing location for ALJ hearing requests. Additionally, in § 405.1106, we incorrectly identified two filing locations for appeals to the Medicare Appeals Council (MAC). We are correcting these errors in section D of this correcting amendment.
In the interim final rule, appellants are permitted to request extensions to the filing deadlines. We intended to state that adjudicators could grant these extensions if appellants provided good cause for extending the deadline. To clarify this policy, we are revising § 405.1014(c)(4) and § 405.1016(b) to state that an “ALJ” rather than an “ALJ hearing office” may grant a request to extend the filing deadline.
ALJs are required to provide notice of a hearing to a number of entities, including all parties to the reconsideration. This is the policy we intended to convey in § 405.1020(c)(1), but the language we used in the interim final rule (that is, “participated in any of the determinations in paragraphs (c) through (i) of this section”) is not sufficiently clear. Therefore, we are revising this section to clarify any ambiguities regarding this requirement and to ensure that hearing notices are issued to the appropriate entities.
Section 405.1028 discusses the pre-hearing review process for evidence submitted to the administrative law judge (ALJ). Although the heading for this section reads “Prehearing case review of evidence submitted to the ALJ by the appellant”, this section discusses evidence submitted by certain other parties. To ensure that the heading properly reflects the content of the section, we are correcting this error in section D of this correcting amendment.
In drafting the interim final rule, we made many revisions to the regulation text, including renumbering certain provisions. When we renumbered sections of the regulation, our intent was to also update any corresponding cross-references to reflect the new numbering scheme. In § 405.1052(a)(4) and § 405.1052(a)(5), however, we inadvertently failed to update the cross-references to reflect the new numbering scheme. Therefore, we are correcting these errors in section D of this correcting amendment.
The binding authority of national coverage determinations (NCDs) is described in § 405.1060. Here, we stated that NCDs are “binding on all Medicare contractors, including QIOs, QICs, Medicare Advantage Organizations, Prescription Drug Plans and their sponsors, HMOs, CMPs, HCPPs, ALJs, and the MAC.” We failed to note, however, that fiscal intermediaries and carriers are also bound by NCDs and further, that some of the entities listed are not subject to all NCDs. We correct this statement in section D of this correcting amendment by revising paragraph (a)(4) to make NCDs binding on fiscal intermediaries, carriers, QIOs, QICs, ALJs, and the MAC.
In the interim final rule, we stated a longstanding policy regarding the calculation of the receipt date of appeal notices; that is, receipt is presumed to be 5 days after the date of the notice, unless there is evidence to the contrary. In this same section, we also established the related policy that an appeal is considered filed on the date that it is received by the appropriate entity. Our intention was to restate these policies in each section where we established the filing deadlines. However, we inadvertently omitted some or all of this information from § 405.974(b), § 405.1002(a), § 405.1004(a), and § 405.1102(a). We are correcting these omissions in Section D of this correcting amendment.
In the interim final rule, we also made a single revision to part 401 regarding the applicability of CMS Rulings. In our revision, we inadvertently failed to encompass the effect of CMS Rulings on matters other than Medicare Part A and Part B. To correct this error, we have removed the specific references to Medicare Part A and Medicare Part B.
Accordingly, 42 CFR chapter IV is corrected by making the following correcting amendments to parts 401 and 405:
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart F is also issued under the authority of the Federal Claims Collection Act (31 U.S.C. 3711).
§ 401.108
2. In § 401.108, paragraph (c) is corrected by removing the phrase “pertaining to Medicare Part A and Medicare Part B”.
§ 405.912
4. Section 405.912 is amended as follows—
A. In paragraph (g) introductory text, the word “assignee” is corrected to “assignor”.
B. In paragraph (g)(1), the word “assignor”, which precedes “and”, is corrected to “assignee”.
5. Section 405.926 is amended by—
(j) Determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions (as opposed to the application of these provisions to a particular claim or claims for Medicare payment for benefits);
(n) Determinations that a provider or supplier failed to submit a claim timely or failed to submit a timely claim despite being requested to do so by the beneficiary or the beneficiary's subrogee;
§ 405.946
6. In § 405.946, paragraph (b), the words “up to” are inserted between “for” and “14”.
§ 405.950
7. In § 405.950, paragraph (b)(3), the words “up to” are inserted between “for” and “14”.
8. Section 405.970 is amended by revising paragraph (c)(2) to read as follows:
Timeframe for making a reconsideration.
(2) Notify the parties that it cannot complete the reconsideration by the Start Printed Page 37703deadline specified in paragraph (b) of this section and offer the appellant the opportunity to escalate the appeal to an ALJ. The QIC continues to process the reconsideration unless it receives a written request from the appellant to escalate the case to an ALJ after the adjudication period has expired.
§ 405.974
9. Section 405.974 is amended by adding paragraphs (b)(1)(i) and (b)(1)(ii) to read as follows:
(i) For purposes of this section, the date of receipt of the contractor's notice of dismissal is presumed to be 5 days after the date of the notice of dismissal, unless there is evidence to the contrary.
(ii) For purposes of meeting the 60-day filing deadline, the request is considered as filed on the date it is received by the QIC indicated on the notice of dismissal.
10. Section 405.980 is amended by—
Reopenings of initial determinations, redeterminations, and reconsiderations, hearings and reviews.
(a) General rules. (1) A reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or underpayment, even though the final determination or decision may have been correct at the time it was made based on the evidence of record. That action may be taken by—
(3) Notwithstanding paragraph (a)(4) of this section, a contractor must process clerical errors (which includes minor errors and omissions) as reopenings, instead of as redeterminations as specified in § 405.940. If the contractor receives a request for reopening and disagrees that the issue is a clerical error, the contractor must dismiss the reopening request and advise the party of any appeal rights, provided the timeframe to request an appeal on the original denial has not expired. For purposes of this section, clerical error includes human or mechanical errors on the part of the party or the contractor such as—
(4) When a party has filed a valid request for an appeal of an initial determination, redetermination, reconsideration, hearing, or MAC review, no adjudicator has jurisdiction to reopen an issue on a claim that is under appeal until all appeal rights for that issue are exhausted. Once the appeal rights for the issue have been exhausted, the contractor, QIC, ALJ, or MAC may reopen as set forth in this section.
(2) An ALJ or the MAC may reopen a hearing decision on its own motion within 180 days from the date of the decision for good cause in accordance with § 405.986. If the hearing decision was procured by fraud or similar fault, then the ALJ or the MAC may reopen at any time.
(2) A party to a hearing may request that an ALJ or the MAC reopen a hearing decision within 180 days from the date of the hearing decision for good cause in accordance with § 405.986.
§ 405.986
11. In § 405.986, remove paragraph (d).
§ 405.990
12. Section 405.990 is amended by revising paragraph (b)(1)(i)(A) to read as follows:
Expedited access to judicial review.
(A) An ALJ hearing in accordance with § 405.1002 and a final decision of the ALJ has not been issued;
§ 405.1002
13. Section 405.1002 is amended by—
(1) The party files a written request for an ALJ hearing within 60 days after receipt of the notice of the QIC's reconsideration.
(3) For purposes of this section, the date of receipt of the reconsideration is presumed to be 5 days after the date of the reconsideration, unless there is evidence to the contrary.
(4) For purposes of meeting the 60-day filing deadline, the request is considered as filed on the date it is received by the entity specified in the QIC's reconsideration.
§ 405.1004
14. Section 405.1004 is amended by—
Right to ALJ review of QIC notice of dismissal.
(1) The party files a written request for an ALJ review within 60 days after receipt of the notice of the QIC's dismissal.
(3) For purposes of this section, the date of receipt of the QIC's dismissal is presumed to be 5 days after the date of the dismissal notice, unless there is evidence to the contrary.
(4) For purposes of meeting the 60-day filing deadline, the request is considered as filed on the date it is received by the entity specified in the QIC's dismissal.
15. In § 405.1014, the phrase “hearing office” is removed from paragraph (c)(4).
§ 405.1016
16. Section 405.1016 is amended by revising paragraphs (b) and (d) to read as follows:
Time frames for deciding an appeal before an ALJ.
(b) The adjudication period specified in paragraph (a) of this section begins on the date that a timely filed request for hearing is received by the entity Start Printed Page 37704specified in the QIC's reconsideration, or, if it is not timely filed, the date that the ALJ grants any extension to the filing deadline.
(d) When CMS or its contractor is a party to an ALJ hearing and a party requests discovery under § 405.1037 against another party to the hearing, the adjudication periods discussed in paragraphs (a) and (c) of this section are tolled.
§ 405.1018
17. In § 405.1018, in paragraph (c), the phrase “must be accompanied by a statement explaining why the evidence is not previously submitted” is corrected to “must be accompanied by a statement explaining why the evidence was not previously submitted.”
18. Section 405.1020 is amended by—
(1) The ALJ sends a notice of hearing to all parties that filed an appeal or participated in the reconsideration, any party who was found liable for the services at issue subsequent to the initial determination, the contractor that issued the initial determination, and the QIC that issued the reconsideration, advising them of the proposed time and place of the hearing.
(4) When a party's request for an in-person hearing is granted, the party is deemed to have waived the 90-day time frame specified in § 405.1016.
§ 405.1028
19. The title of § 405.1028 is corrected to “Prehearing case review of evidence submitted to the ALJ”.
§ 405.1037
A. In paragraph (a)(1), the words “or its contractor” are inserted after “CMS”.
B. In paragraph (c)(1), the word “hearing” at the end of the paragraph is removed.
C. In paragraph (e)(2)(iv), the phrase “where the MAC grants a request for review made by a party other than CMS of a ruling” is corrected to “where the MAC grants a request, made by a party other than CMS, to review a discovery ruling.”
§ 405.1042
21. In § 405.1042, paragraph (a)(3), the phrase “[t]he appellant” is corrected to “[a] party”.
22. In § 405.1046, paragraph (d), the phrase “when the request for hearing is received in the ALJ hearing office” is corrected to “when the request for hearing is received by the entity specified in the QIC's reconsideration.”
23. Amend § 405.1052 as follows:
A. In paragraph (a)(4), the cross-reference to “§ 405.1014(d)” is corrected to “§ 405.1014(c)”.
B. In paragraph (a)(5)(iii), the cross-reference to “§ 405.1020” is corrected to “§ 405.1014”.
§ 405.1060
24. Section 405.1060 is amended by revising paragraph (a)(4) to read as follows:
Applicability of national coverage determinations (NCDs).
§ 405.1102
Request for MAC review when ALJ issues decision or dismissal.
(a)(1) A party to the ALJ hearing may request a MAC review if the party files a written request for a MAC review within 60 days after receipt of the ALJ's decision or dismissal.
(2) For purposes of this section, the date of receipt of the ALJ's decision or dismissal is presumed to be 5 days after the date of the notice of the decision or dismissal, unless there is evidence to the contrary.
(3) The request is considered as filed on the date it is received by the entity specified in the notice of the ALJ's action.
(b) A party requesting a review may ask that the time for filing a request for MAC review be extended if—
(3) It explains why the request for review was not filed within the stated time period. If the MAC finds that there is good cause for missing the deadline, the time period will be extended. To determine whether good cause exists, the MAC uses the standards outlined at § 405.942(b)(2) and § 405.942(b)(3).
§ 405.1104
26. Amend § 405.1104 as follows:
A. The word “latter” is corrected to “later” in paragraph (a)(2).
B. In paragraph (c), the phrase “and the appellant does not request escalation to the MAC” is removed.
§ 405.1106
27. Section 405.1106 is amended by revising paragraph (a) to read as follows:
Where a request for review or escalation may be filed.
(a) When a request for a MAC review is filed after an ALJ has issued a decision or dismissal, the request for review must be filed with the entity specified in the notice of the ALJ's action. The appellant must also send a copy of the request for review to the other parties to the ALJ decision or dismissal. Failure to copy the other parties tolls the MAC's adjudication deadline set forth in § 405.1100 until all parties to the hearing receive notice of the request for MAC review. If the request for review is timely filed with an entity other than the entity specified in the notice of the ALJ's action, the MAC's adjudication period to conduct a review begins on the date the request for review is received by the entity specified in the notice of the ALJ's action. Upon receipt of a request for review from an entity other than the entity specified in the notice of the ALJ's action, the MAC sends written notice to the appellant of the date of receipt of the request and commencement of the adjudication time frame.
28. In § 405.1112, paragraph (a), the phrase “must be made on a standard form” is corrected to “may be made on a standard form”.
§ 405.1136
29. In § 405.1136, paragraph (d)(1), in the first sentence, the words “is filed” are removed.
We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect. However, we can waive this procedure if we find good cause for doing so, and incorporate a statement of this finding and the reasons for it into the rule. A finding that a notice and comment period is impracticable, unnecessary, or contrary to the public interest constitutes good cause for waiving this procedure. We also can waive the 30-day delay in effective date under the Administrative Procedure Act (5 U.S.C. 553(d)) when there is good cause to do so and we publish in the rule an explanation of our good cause.
Many of the corrections included in this rule are corrections of typographical errors and editorial mistakes. For example, the word “mirror” has been corrected to “minor” in § 405.980(a)(3). The rest of the corrections are made to correct inadvertent omissions and clarify inconsistencies in the preamble and regulation text. At § 405.1046(d), for example, consistent with the provision at § 405.1014(b)(2), which states that the proper filing location for ALJ hearing requests is the entity specified in the QIC's reconsideration, the regulation text has been revised to reflect the proper filing location for ALJ hearing requests.
We believe that it is unnecessary to seek public comment on the correction of typographical and editorial errors. Further, it is in the public's interest to correct inadvertent omissions and clarify apparent inconsistencies in the preamble and regulation text. These revisions help ensure that the rules governing the Medicare administrative appeals process are more understandable and less ambiguous and protect the rights of all parties to pursue Medicare claims appeals under these procedures. Therefore, we find that undertaking notice and comment rulemaking to incorporate these corrections into the interim final rule is unnecessary and contrary to the public interest.
For the same reasons, we believe that delaying the effective date of these corrections beyond July 1, 2005 would be contrary to the public interest. As a matter of good public policy, the regulations governing the Medicare claims appeals process should be as accurate and clear as possible. Thus, it would be contrary to the public interest to delay implementation of these corrections to provide for a 30-day delay in effective date. Therefore, we also find good cause to waive the 30-day delay in effective date.