Provider Types Affected
Physicians, providers, and suppliers who appeal initial claims determinations by Medicare

Provider Action Needed
The purpose of CR 3939 is to notify Medicare contractors (fiscal intermediaries (FIs) or carriers, including durable medical equipment regional carriers (DMERCs)) and Medicare providers about the upcoming transition to the new second level of the appeals process.

The Medicare claim appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 1869(c) of the Social Security Act (the Act), as amended by BIPA, requires a new second level in the administrative appeals process called a “reconsideration.” This new “reconsideration” is different from the previous first level of appeal for Part A claims performed by FIs. Reconsiderations will be processed by Qualified Independent Contractors (QIC).

Rather than repeat the extensive details of CR 3939 in this article, the Centers for Medicare & Medicaid Services (CMS) encourages physicians, providers, and suppliers who wish to appeal an initial determination of a Medicare claim made by a Medicare carrier or FI to review CR 3939. The new/revised manual sections of Chapter 29 of the Medicare Claims Processing Manual that are attached to CR 3939 contain many important details for those wishing to file claims determination appeals. You can find CR 3939 by going to http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. From that Web page, look for CR 3939 in the CR NUM column on the right, and click on the file for that CR.

The key new or revised sections contained in CR 3939 include information on:

• Filing a request for redetermination;
• Appeal rights for dismissals of redetermination requests, including sample dismissal letters and notices;
• Filing requests for reconsiderations, the second level of appeal;
• Time limits for filing reconsideration requests; and
• How reconsideration decisions are effectuated.

If you bill a Medicare FI, you may also wish to review Medlearn Matters article MM3530 and/or CR 3530.

They are available as follows:

Medlearn Matters article MM3530 MMA - Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-“Appeals Transition – BIPA 521 Appeals”) is available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3530.pdf on the CMS Web site.

CR 3530 Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-“Appeals Transition –

BIPA 521 Appeals”) is available at http://www.cms.hhs.gov/Transmittals/downloads/R146OTN.pdf on the CMS Web site.

Please refer to your local FI, carrier, or DMERC if you have questions on this issue. To find their toll-free phone numbers go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf 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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.

Pub. 100-4, Transmittal# 724 , CR# 3939
Medlearn Matters Number: MM 3939

Related CR Release Date: October 21, 2005

Effective Date: January 1, 2006, for appeals of initial determination of claims by Medicare carriers; May 1, 2005, for initial claim determinations by Medicare Fiscal Intermediaries (FIs)
Implementation Date: December 16, 2005, for FIs and January 1, 2006, for carriers

Posted: 12/02/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.