National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Appeals Transition - BIPA Section 521 Appeals (MM5460)

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MAC), Fiscal Intermediaries (FI), Part A/B Medicare Administrative Contractors (A/B MAC), and/or Regional Home Health Intermediaries (RHHI)) for services provided to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5460, which notifies Medicare contractors about their need to comply with changes to provisions in Chapter 29 of the Medicare Claims Processing Manual (Publication 100-04) that address the appointment of representatives, fraud and abuse, guidelines for writing appeals correspondence, and the disclosure of information.

Background
The Medicare claims appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) and the Medicare Prescription Drug Improvement and Modernization Act (MMA). The Social Security Act (Section 1869(c)), as amended by BIPA and MMA, requires changes to the Code of Federal Regulations (CFR; Title 42) regarding:

• Appointment of representatives,
• Fraud and abuse,
• Guidelines for writing appeals correspondence, and
• The disclosure of information.

Therefore, the Centers for Medicare & Medicaid Services (CMS) is revising provisions in Chapter 29 of the Medicare Claims Processing Manual that address these changes.

The purpose of CR5460 is to notify Medicare contractors about their need to comply with these revised Medicare Claims Processing Manual provisions, which are included as an attachment to CR5460.

Some of the key changes to the manual direct Medicare contractors to:

• Follow the procedures that define who may be a representative and how a representative is appointed (via the CMS-1696 Appointment of Representative (AOR) form);
  • Do not accept an appointment if the contractor has evidence that the appointment should not be honored;
  • Send notice only to the representative when the contractor takes action or issues a redetermination [if there is an appointed representative];
  • Provide assistance in completing the CMS-1696 form, as needed; and
  • Do not release beneficiary-specific information to a representative before the beneficiary or appellant and the prospective representative have completed and signed the CMS-1696 or other conforming written instrument.
    
  Please note that the AOR applies to all services, claims and appeals submitted on behalf of the beneficiary for the duration of the AOR.

• Follow the procedures that describe the process a beneficiary must use to assign their appeal rights to a provider (via the CMS-20031) Transfer of Appeal Rights form):
  • For each new appeal request, a form needs to be submitted, this form is valid for all levels of the appeal process including judicial review, even in the event of the death of the beneficiary;
  • If a provider furnishes the service, he/she would be a party to the initial determinations, only providers or suppliers who are not a party may accept assignment of appeal rights from a beneficiary. That is assignment of appeal rights applies only to providers and suppliers who are never a party to an appeal because they do not participate in Medicare and have not taken the claim on assignment; and
  • The provider or supplier who accepts the appeal rights to collect payment from the beneficiary for the item or service that is the subject of the appeal. The provider or supplier may collect any applicable deductible or coinsurance. The provider or supplier agrees to this waiver by completing and signing Section II of the Transfer of Appeal Rights form.
• Provide redetermination letters that are understandable to beneficiaries.

Please note that an Assignment of Appeal Rights is valid for the duration of an appeal unless it is revoked by the beneficiary.

Additional Information
The official instruction, CR5460, issued to your Medicare contractor regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1274CP.pdf on the CMS Web site. The revised portions of the Medicare Claims Processing Manual are attached to that CR.

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found on the CMS Web site 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: MM5460
Pub. 100-4, Transmittal# R1274CP, CR# 5460
Related CR Release Date: June 29, 2007
Effective Date: July 1, 2007
Implementation Date: October 1, 2007