Appeals

A party dissatisfied with an initial Medicare determination may appeal the decision in writing. There are several appeal levels and each level must be processed before proceeding to the next level.

Appeals Process for 2010

For specific details on the Medicare Appeals Process please refer to IOM – Publication 100-4, Chapter 29 http://www.cms.hhs.gov/default.asp?

After receiving the initial determination, there are five levels in the appeals process. Each level has procedural steps the appellant must take before appealing to the next level. If the appellant meets the procedural steps at a specific level, the appellant is then afforded the right to appeal any determination or decision to the next level in the process. The appellant may exercise the right to appeal any determination or decision to the next higher level, until appeal rights are exhausted.

Although there are five distinct levels in the Medicare Part A appeals process, the redetermination, the first level, is the only level performed by the Medicare Part A contractor. If an appellant is dissatisfied with this first level of appeal, a request must be sent to the Qualified Independent Contractor (QIC) by the appellant. If the appellant is dissatisfied with this second level, the appellant can request a hearing from the Administrative Law Judge (ALJ) hearing, level 3. To do so, a request must be made in writing to the Office of Medicare Hearings and Appeals (OMHA). If the decision is still dissatisfactory, the appellant may request a review within the Departmental Appeals Board. If an appellant has exhausted these first four levels, the appellant may appeal to the Federal courts, provided the appellant satisfies the requirements for obtaining judicial redetermination.

In the chart below is the administrative appeals process. Each level of appeal must be exhausted before moving to the next level.

• The Beneficiary;
• The provider of services;
• A Medicaid State agency, or party authorized to act on behalf of the State;
• A provider who otherwise does not have the right to appeal may appeal when the beneficiary dies and there is no other party available to appeal
• Any individual whose rights with respect to the particular claim being reviewed may be affected by such review and any other individual whose rights with respect to supplementary medical insurance benefits may be prejudiced by the decision (e.g., an individual or entity liable for payment under 42 CFR Subpart E 424.60 in a case of a deceased beneficiary).

Note: While a representative may request an appeal on behalf of the party that he/she represents, the representative is not considered a party himself/herself solely by virtue of being a representative.

How to Request a Redetermination/Required Elements of a Redetermination with the Contractor
Parties with appeal rights must submit written requests indicating what they are appealing and why.

A completed Form CMS-20027 constitutes a request for redetermination. The contractor can supply these forms upon request by an appellant. They can also be downloaded from the CMS website at http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf Completed means that all applicable spaces are filled out and all necessary information (reports, medical records, etc.) is attached.

A written request not on Form CMS-20027. The request contains the following information:

• Beneficiary name
• Medicare health insurance claim (HIC) number;
• The specific service(s) and/or items for which the redetermination is being requested;
• The specific date(s) of the service; and
• The name and signature of the party or the representative of the party.

NOTE: Some redetermination requests may contain attachments. For example, if the Remittance Advice (RA) is attached to the redetermination request that does not contain the dates of service on the cover, but the dates of service are highlighted or emphasized in some manner on the attached RA, this is an acceptable redetermination request.

Incomplete Requests – The requirements for written requests for redeterminations are found in IOM Publication 100-04, Chapter 29, Section 310.1(B)(s) (Note: Beneficiary requests are never considered incomplete, see Section 310.1(B)(1). Contractors must handle and count incomplete redetermination requests as dismissals. The above requirements under Section 310.6.2 for vacation and appealing dismissal apply to incomplete requests as well. Parties to the redetermination also have the option to refile their request if any time remains in the filing period (i.e., 120 days from receipt of the initial determination). When a request is filed that meets the requirements, the previous dismissal is vacated and reopened.

Filing a Request for a Reconsideration with the QIC
The request for a reconsideration made by a beneficiary, provider, supplier, or State and must be filed with the QIC (Q2 Administrators, LLC) specified in the redetermination notice. A request from a provider, supplier, or State must be made in writing either on a CMS-20033 form which is available from http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf or included with the redetermination, or must contain the following items:

• The beneficiary’s name;
• Medicare health insurance claim number;
• The specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service;
• The name and signature of the party or representative of the party; and
• The name of the contractor that made the redetermination.

If you have any questions about the appeals process, or what your next step in the appeals process is, please contact Customer Service.

Clerical Error Reopening or Redetermination?

Part A J14 Reopening Request Form

Clerical Error Reopening: The purpose of a clerical error reopening is to correct a minor error or omission from the original claim submission. Requests for adjustments to claims, which result from clerical errors, can be handled through the reopening process. If a claim may be corrected through the electronic adjustment process, it is encouraged that this process continues to be followed.

Examples of when a case will be considered a reopening are:

• When incorrect information was included on the claim and it resulted in an automatic denial by the claim processing system
• When the claim was rejected due to screening time limits and the service was billed incorrectly as screening

Examples of when a case will not be considered a reopening are:

• The claim was manually reviewed by Medical Review, Program Safeguard Contractor (PSC), CERT or RAC
• The denial is not an automated denial
• Adding or removing a GA modifier
• The claim may be corrected through the normal electronic adjustment process

The provider must provide:

• The specific code or error they made
• The correction they want made

The request for clerical error reopening may state any of the following:

• “Please add this diagnosis code” (the specific code must be included and not only a narrative description of the diagnosis)
• “We billed the claim incorrectly, please remove the listed procedure code and replace it with this”
• “We billed the claim incorrectly, please remove the listed HCPC code and replace it with this”

Issues that may be handled as a clerical error reopening (this is not an all inclusive list):

• Billed screening and meant to bill diagnostic, or vice versa
• Automated Denial based on a Local or National Coverage Determination (LCD/NCD) where diagnostic information was not coded correctly on the initial claim submission

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07/01/2010