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Issue 2006-04, April 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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MMA - Changes to Chapter 29 - Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Date May 1, 2005)
Note: This article was revised on February 21, 2006, to update the language regarding the appeals process. In addition, the article now contains Web addresses that conform to the new CMS Web site. |
Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare for services
Provider Action Needed
The new second level in the administrative appeals process is called a “reconsideration.” Reconsiderations are processed by Qualified Independent Contractors (QIC).
Background
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, now requires a new second level in the administrative appeals process called a reconsideration.
Requests for reconsideration of appeal decisions (redeterminations) should go either to the Qualified Independent Contractor (QIC), or the Hearing Officer (HO), when the redetermination was issued by a carrier prior to January 1, 2006.
Time Limit for Filing a Request for Reconsideration
A request for reconsideration must be filed within 180 days of the date of receipt of the notice of redetermination. For requests filed in writing - the date received is defined as the date received by the QIC in the corporate mailroom.
Please refer to the following table for clarification.
Appeal Rights for Requests for Reconsideration
The Second Level of Appeal
| Medicare Claims |
Medicare Contractor Issuing Redetermination |
Date Redetermination Issued and Mailed |
Where to Appeal the Redetermination* |
Part A/Part B |
FI |
On or after May 1, 2005 |
QIC |
Part B |
Carrier |
On or after January 1, 2006 |
QIC |
Part A |
FI |
Before May 1, 2005 |
ALJ |
Part B |
FI |
Before May 1, 2005 |
HO |
Part B |
Carrier |
Before January 1, 2006 |
HO |
*Qualified Independent Contractor (QIC); Administrative Law Judge (ALJ); Hearing Officer (HO) |
Additional Information
Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims Decisions, 310.2, 310.3, can be found at http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf  on the CMS Web site.
Medlearn Matters article MM3530 - “MMA - Revisions to Medicare Appeals Process for Fiscal Intermediaries Revised: 4/12/2005” (CR Title - Appeals Transition - BIPA 521 Appeals), can be found at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3530.pdf on the CMS Web site.
Change Request CR3530 “Revisions to Medicare Appeals Process for Fiscal Intermediaries Revised: 4/12/2005” (CR Title-Appeals Transition – BIPA 521 Appeals), can be found at http://www.cms.hhs.gov/Transmittals/downloads/R146OTN.pdf on the CMS Web site.
The official instruction issued to your FI, DMERC, or carrier regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R697CP.pdf on the CMS Web site.
The new sections of Chapter 29 of the Medicare Claims Processing Manual are attached to CR3942.
Please refer to your local carrier/DMERC/FI for more information about this issue. To find the toll-free phone number, go to http://www.cms.hhs.gov/apps/contacts/  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.
Pub. 100-4, Transmittal# 697 , CR# 3942
Medlearn Matters Number: MM3942 Revised
Related CR Release Date: October 7, 2005
Effective Date: May 1, 2005
Implementation Date: January 9, 2006
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