NOTE: Effective with decisions made on or about August 1, 2006, providers will no longer receive a Medicare Redetermination Notice when a fully favorable decision is made on the appeal. In these cases, the provider will see the claim processed on a future remittance notice (usually within 30 days). The highlighted areas explain the information that is contained in the paragraphs of the Medicare Redetermination Notice and below is an example from an actual letter. Along with a Medicare Redetermination Notice, you will receive a copy of the Reconsideration Request form. If you do not agree with the decision, you can request the next level of appeal.
Dear Medicare Provider, This letter is to inform you of the decision on your Medicare appeal. An appeal is a new and independent review of a claim. You are receiving this letter because you made an appeal This appeal decision is UNFAVORABLE. Our decision is that your claim is not covered by Medicare More information on the decision is provided below. You are not required to take any action. However, if you disagree with the decision, you may appeal to a Qualified Independent Contractor. You must file your appeal, in writing, within 180 days of receiving this letter The Reconsideration Request form is attached to facilitate this process. Empire Medicare Services was contracted by Medicare to review your appeal. For more information on how to appeal, see the page titled Important Information About Your Appeal Rights.
*A claim was sent by Hospital A for a diagnostic mammography on September 11, 2004. *The first decision was made on the following date(s): June 24, 2005. *The service was denied because the information provided does not support a medical need for this service. *We received a request for an appeal on July 5, 2005. *The following was sent with the request: medical records.
We have decided that the above services are not covered by Medicare. We have also decided that the provider is responsible for payment of the services.
Review of the records was based on Local Coverage Determination A diagnostic mammogram is a covered Medicare service when there are signs and symptoms such as a mass, skin changes, discharge or pain. It is also a covered Medicare service if there are problems found on a screening mammogram. It may also be covered for the follow-up of clinical or radiographic concerns that have not been resolved. A diagnostic mammogram is covered for the purpose of follow-up when there is a history of breast malignancy. A review of the record shows Jane Doe was seen at Hospital A for diagnostic mammography services on September 11, 2004. She was seen for pain and numbness in the breast region. The records sent did not include a doctor's order or a mammography report. Therefore, no Medicare payment can be made.
Because we decided that some or all of the services were not covered by Medicare, we must decide according to 1879 of Title XVIII of the Social Security Act, whether the patient and/or provider knew or could have been expected to know that the services would not be covered under Medicare. The first Medicare decision held the provider responsible for the cost of the noncovered service(s). Our review agrees. If payment was made for the part of the claim the provider is responsible for, the patient or person chosen must write to Empire Medicare Services Beneficiary Inquiries. Write to them within six months of this letter. Include the following:
Please include doctor's orders for all services billed.
Special Note to Medicare Providers Only: Any evidence indicated in this notice must be submitted to the QIC. It should accompany the request for reconsideration. All evidence, including evidence that is not indicated in this notice, must be presented before the reconsideration is issued. If all evidence is not submitted, you will not be able to submit any new evidence in subsequent appeals unless you can demonstrate good cause for not presenting the evidence to the QIC. This evidence requirement also applies to providers who represent beneficiaries in the appeals process.
If you need more information or have any questions, please call 1-800-MEDICARE (1-800-633-4227) (Beneficiary) or 1-888-855-4356 (Provider).
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS Your Right to Appeal this Decision: If you do not agree with this decision, you may file an appeal. An appeal is a review performed by people independent of those who have reviewed your claim so far. The next level of appeal is called reconsideration. A reconsideration is a new and impartial review performed by a company that is independent from Empire Medicare Services. How to Appeal: To exercise your right to an appeal, you must file a request in writing within 180 days of receiving this letter. Under special circumstances, you may ask for more time to request an appeal. You may request an appeal by using the form enclosed with this letter. If you do not use this form, you can write a letter. You should include: your name, your signature, the name of the beneficiary if you are not the beneficiary requesting the appeal, the Medicare number, a list of the service(s) that you are appealing and the date(s) of service, and any evidence you wish to attach. You must also indicate that Empire Medicare Services made the redetermination. You may also attach supporting materials such as medical records, doctors' letters, or other information that explains why this service should be paid. Your doctor may be able to provide supporting materials. If you want to file an appeal, you should send your request to: MAXIMUS Federal Services Who May File an Appeal: You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. If you want someone to act for you, you and your appointed representative must sign, date and send us a statement naming that person to act for you. Call us to learn more about how to name a representative. Help with Your Appeal: If you want help with an appeal, or if you have questions about Medicare, you can have a friend or someone else help you with your appeal. You can also contact your State Health Insurance Assistance Program (SHIP). You can call 1-800-MEDICARE (1-800-633-4227) for information on how to contact your local SHIP. Your SHIP can answer questions about payment denials and appeals. Other Important Information: If you want copies of statutes, regulations, policies, and/or manual instructions we used to arrive at this decision, please write to us at the following address and attach a copy of this letter: Empire Medicare Service If you need more information or have any questions, please call us at the phone number provided. Other Resources to Help You: 1-800-MEDICARE (1-800-633-4227), TTY/TDD: 1-877-486-2048 Page Last Modified: 10/05/07 |
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