MIR-2007 06AB, June 2007

Modification to the Model Medicare Redetermination Notice (MRN) (for partly or fully unfavorable redeterminations) and the Administrative Law Judge (ALJ) Filing Locations Where the Place of Service Was in Delaware, Kentucky, Puerto Rico, Virginia, and/or the US Virgin Islands. (MM5554)

Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare contractors (fiscal intermediaries (FI), carriers, Part A/B Medicare Administrative Contractors (A/B MAC), DME Medicare Administrative Contractors (DME/MAC), Durable Medical Equipment Regional Carriers (DMERC), and/or Regional Home Health Intermediaries (RHHI))

Provider Action Needed

Impact to You
The Centers for Medicaid & Medicare Services (CMS) issued change request (CR) 5554 in order to modify the Reconsideration Request Form and to amend the ALJ filing locations.

What You Need to Know
Providers and suppliers do not need to resubmit documentation when requesting a Qualified Independent Contractor (QIC) reconsideration if the documentation was previously submitted as part of the redetermination process. This documentation is forwarded to the QIC as part of the case file utilized in the reconsideration process. Make certain that any additional evidence is submitted prior to the reconsideration decision. If all additional evidence is not submitted prior to issuance of the reconsideration decision, you will not be able to submit any new evidence to the ALJ or further appeal unless you can demonstrate good cause for withholding the evidence from the QIC.

Be aware that when the service was rendered in Delaware, Kentucky, Virginia, Puerto Rico, and/or the US Virgin Islands, the filing locations for ALJ requests are modified to identify the appropriate Office of Medicare Hearings and Appeals (OMHA) field office. All other jurisdictions remain unchanged.

What You Need to Do
Make certain that your billing staff or other staff that handle reconsideration requests for you are aware of these changes.

Background
CR5554 is the official document that announces these changes in Medicare processes. Attached to this CR are three documents that assist with the appeals process:

• A sample form letter titled: Medicare Appeal Decision,
• A paper outlining Important Information About Your Appeal Rights, and
• A modified Reconsideration Request Form containing revised introductory instructions, as follows: “At a minimum, you must complete/include information for items 1, 2a, 6, and 7 but to help us serve you better, please include a copy of the redetermination notice you received with your reconsideration request.”

The revised filing locations for sending documentation for requesting ALJ hearings are as follows:

• Cleveland , Ohio is the filing location for services rendered in Delaware and Kentucky,
• Arlington, Virginia for services in Virginia, and
• Miami, Florida for services in Puerto Rico and the US Virgin Islands.

The following table lists the addresses of all filing locations along with the place of service.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5554) issued to your Medicare carrier, FI, A/B MAC, DME MAC, DMERC, or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1229CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, FI or A/B MAC, DME MAC, or RHHI at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5554
Pub. 100-4, Transmittal# R1229CP, CR# 5554
Related CR Release Date: April 27, 2007
Effective Date: July 2, 2007
Implementation Date: July 2, 2007

Medicare Fee-For-Service (FFS) Contingency Plan Announced!

Effective May 23, 2007, Medicare FFS is establishing a contingency plan for implementing the National Provider Identifier (NPI). In this plan, as soon as Medicare considers the number of claims submitted with an NPI for primary providers (Billing, pay-to and rendering providers) is sufficient, Medicare (after advance notification to providers) will begin rejecting claims without an NPI for primary providers, perhaps as early as July 1, 2007. For more information on this contingency plan, please visit the NPI dedicated Web site at http://www.cms.gov/hhs.nationalprovidentstand/