Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare for services

Provider Action Needed
Medicare providers who appeal claims decisions made by Medicare carriers and fiscal intermediaries (FIs), including durable medical equipment regional carriers (DMERCs) and regional home health intermediaries (RHHIs), need to be aware of the new appeals processes.

Background
The purpose of CR 3944 is to notify Medicare contractors (FIs or carriers, including DMERCs) and Medicare providers about the upcoming transition to the new second level of the appeals process.

The “redetermination”is the first level of appeal. It is a second look at the Part A or B claim and supporting documentation by an employee of the contractor (Medicare carrier or intermediary) who was not involved in the initial claim determination. In performing a redetermination of the services requested by the appellant, Medicare contractor personnel must examine all issues in the claim.

The Medicare claims 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. These appeals are processed by Qualified Independent Contractors (QIC).

Additional Information
Rather than repeat the extensive details of CR 3944 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 3944. The new/revised manual sections of Chapter 29 of the Medicare Claims Processing Manual that are attached to CR 3944 contain many important details for those wishing to file claims determination appeals. You can find CR 3944 by going to http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. From that Web page, look for CR 3944 in the CR NUM column on the right, and click on the file for that CR.

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.

In addition, if your request for a redetermination is dismissed by the Medicare contractor, you may wish to understand your appeal rights with regard to that dismissal. These rights are discussed in CR 3939, which can also be found at http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. Once at that page, look for CR 3944 in the CR NUM column on the right and click on the file for that CR.

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 #: 688 , CR# 3944
Medlearn Matters Number: MM3944

Related CR Release Date: September 23, 2005

Effective Date: May 1, 2005, for appeals of claims submitted to Medicare intermediaries and January 1, 2006, for appeals of claims submitted to carriers
Implementation Date: December 16, 2005, for Medicare intermediaries and January 1, 2006, for Medicare 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.