Questions & Answers - Appeals Process

Ask the Contractor Teleconference

Date: May 26, 2005

Topic: Appeals Process

Questions and Answers (Q&A)

Question: We were told that Telephone Appeals would be discontinued in June, is this true?

Answer: The telephone appeals process will be scheduled to be eliminated January 1st. We did not mention it during this presentation because we don’t have a final documentation from CMS; however, it is an anticipated change for 2006.

Question: Where exactly can we obtain form # 20027?

Answer: That is accessible from the CMS website at http://www.cms.hhs.gov/forms.

Question: What is the first level of appeals?

Answer: Redetermination.

Question: Please cover the changes that will take place in 2006 for the hearings.

Answer: Effective January 1, 2006 any requests for hearings following the initial determinations made on or after January 1, 2006 will no longer have hearing officer rights; but will have Appeal rights to the Qualified Independent Contractors “QICs”. The name of the process has been changed and is called reconsideration”. All redeterminations made in 2005 however will continue being eligible for a hearing held by a Hearing Officer.

Question: Massachusetts no longer has a toll free number to call for Appeals. Why is that other states appear to have them?

Answer: It is something that wasn’t required by the Internet Only Manual and since we were losing the Telephone Appeals at the end of the year, a decision was made to go with the regular phone number because our other three states don’t have a toll free number.

Question: Are we going have to submit all appeals request in writing as of January 1st?

Answer: Yes.

Question: So no Appeals would be performed over the Telephone?

Answer: We are not exactly sure how the process is going to work as of yet. However it is our understanding that if your remittance is dated prior to January 1, 2006 you will still have the option of a Telephone Appeal. So for the beginning of the year we will probably have some type of telephone appeals open for those remittances prior to 1/1/06.

Question: How about the hearing level after 2006, will we no longer be able to speak with a hearing officer?

Answer: For hearing requests associated with claims completed in 2005 Hearing Officers will still be available in 2006. We do not know the details of what the “QICs” are going to be doing at this time.

Question: Is it true if the claim was adjudicated or reviewed the redetermination was reached on a case in 2005 it will still be addressed by a Hearing Officer in 2006?

Answer: Correct.

Question: Is there a proper stipulation of time for processing of a redetermination?

Answer: It is 60-days from date of receipt of your redetermination requests.

Question: Are we able to fix the dates of service on the appeals line?

Answer: I have my northern CA. team on the line. On this day in northern CA you are not allowed to change the date of service on the Appeals Line. That has to be addressed through written inquiries.

Question: What can we do on the Appeals Line?

Answer: You can make changes on date of service, change to certain modifiers, ICD-9 codes. If there is something that needs to have additional documentation for medical necessity denial.

Question: If we had billed under an incorrect Provider Number, can we fix those on the Appeals Line or do we do written inquiries on those?

Answer: No, that would be considered a billing error. And all billing errors need to be sent to the Written Inquiries Department.

Question: In regards to the Contractor that’s going to start taking over this process is that effective January 1st too?

Answer: Yes. Although the QICs are taking over the hearing process. With regards to the dates of service that is on the telephone redetermination line in Southern CA. we do it up on dates of service.

Question: Do you need a copy of the claim and supporting documents as well when requesting a redetermination?

Answer: For redetermination, yes we need a copy of the claim. You have to build your case in addition to those items, those bulleted items I just gave you, and the redetermination notice and any substantiating documents to support the need for the appeal.

Question: When requesting a hearing do you sent same type of information that you sent for a redetermination?

Answer: You have to build your case, give the same information that you submitted on the first level of redetermination and maybe additional information. At the hearing level again you will give the initial claim; remittance advice statement, a copy of your request for your appeal along with a copy of redetermination notice that you received and any additional information that you may have to support the need. Make sure that you identify what type of hearing you want to request; either on-the-record telephone or in-person hearing.

Question: The Federal Court Level, how much would have to be in the dollar amount?

Answer: $1,050.00 effective January 1, 2005 through December 31, 2005. Effective January 1, 2006, the amount is $1090.00.

Question: Regarding the 60-day Appeal processing time; when calling Customer Service, they cannot find any notes regarding their Appeal file. Is there any way that Medicare can set up codes so that when we follow up – Customer Service can respond that at least we received their Appeal? Caller in Massachusetts.

Answer: As soon as an Appeal is entered into the system by the Appeals Department whether they finalize it, pend it for further research it does show in our files.

Question: Do you use any specific codes for Appeal claim?

Answer: Yes, there are specific reason codes for Appeal claims. There’s also a comment file in the system where they place a comments.

Question: For the second level, the form CMS 1965, where do we retrieve that form?

Answer: The form is available on the CMS website at http://www.cms.hhs.gov/forms.

Question: Is the form required when we request a hearing?

Answer: No, however all of the information that is asked you to provide must be presented in a cover letter. It seems like an easier way to send the information to make sure that you cover all of the requirements. You’re not required to use it.

Question: Will this take the place of a cover letter or would it be an addition with the cover letter?

Answer: That’s going to be in lieu of/ in replacement of. You need to give any substantiating document that you may want considered on the case.

Question: Calling from New England. Question regarding the clerical errors that we’re talking about. My understanding is that we have four years to re-open, is that correct?

Answer: That is correct with just cause. In the IOM, there are specific reasons the CMS finds acceptable for just cause. Staffing issues do not constitute just cause. What would be just cause would be Acts of God, weather, flooding and/or fire.

Question: Would that include “computer conversion: with lots of information?

Answer: No. That would be something not justifying our timely filing limits.

Question: Do you still use the written redetermination form in order to request the re-opening?

Answer: No you can simply either write in to our Correspondence or Adjustments department or you can contact our Customer Service.

Question: A re-opening is we made any errors and we submitted the claims and a redetermination as if we want you to reconsider additional information for medical necessity or something like that.

Answer: Exactly. With the re-opening, you’re not asking us to exercise your appeal rights. You’re asking us to repair or adjust the original claim versus applying your appeal rights.

Question: Would we just be able to submit a new claim for re-opening and make the changes on the claim?

Answer: No we have to be able to administratively go in to the original claim that was processed and rework that original claim or re-open the original claim.

Question: There’s not a form that we need to fill out and that we could send a cover letter?

Answer: A cover letter would be appropriate. CMS has not come up with a form for that. Make sure you include a copy of the Remittance Notice so that we can go back to the original claim.

Question: We also are having problems where we send in our appeals and then when we call because we haven’t heard of any redetermination. They told us they don’t have them. So that 60-days thing is not applying to us either, and we’re using the right form. We don’t send it certified though. What is your process when you receive the Appeals, how do they get logged into the system and is there is a time frame that you allow it to get logged in the system, are you behind logging it? Are there going to be no telephone appeal for Southern CA also for 2006?

Answer: I’ll answer your last question first. Yes, it is going to be eliminated in 2006. There’s going to be additional information on it that will be posted on our website so you have more specifics as to its effective date and any other recourses that you would have available.

With regards to your question on how the claims are being logged in and the timelines of that. Peter, here in Southern CA, will give us information on that. (Peter) When an appellant submits their first level of appeal which is the redetermination, that is sent to the appropriate PO Box for the Southern CA Redetermination’s Unit, it goes to the mailroom which is located in Chico, CA (in Northern CA), and they in turn assign a Control Number to each requests that is made. That information (the documents) are forwarded to the appropriate office in Southern CA or the Northern CA NHIC offices, and at that point, once it’s received in the Redetermination’s Unit, those Correspondence Control Numbers, which are written on your documents (when you’re requesting an Appeal in Redetermination) , are entered into a computer system, so that anyone, including the Customer Service personnel can access it and see that indeed we have received your Redetermination request. Now, much to the point that was made earlier in regards to another caller who had a similar problem, it could also be driven by what information is being given to the Customer Service representative in the Call Center. If you give them a particular claim, that particular claim may not necessarily be the initial redetermination claim. Perhaps you may need to give them the date of service in which the Customer Service representative can check the Correspondence history file of that particular beneficiary and find the initial - determination claim number from which they will find it linked to the Control Number for your Appeal request.

Question: The time frame involved in going to the Chico mailroom in Northern CA issuing the control number and sending it out to Southern CA and putting it in your computer system is how many days in your opinion?

Answer: Average is about seven to ten days.

Question: We have gone through the Hearing Officer and have asked for and adjudicate an appeal and we have the adjudication and yes we can have the appeal, what is the time frame for us to get a date for that adjudicated hearing? It’s more than 60 days, at this point, that we could have it?

Answer: The Office of Adjudication and Appeals is responsible for that process. What we do here is assess your request, put together the case file, and we send you a letter saying that your file has been forwarded to the Office of Hearing and Appeals. And we also give you a number where you can call to follow-up on your request. If you have some problems, you can call us and we’ll try to track your case and see if we can locate the local office who had your case.

Question: March 10th, we requested an Administrative Law Judge hearing. And we have yet to hear on a date for that hearing.

Answer: You have yet to receive a schedule from the ALJ? We don’t have anything to do with that. We don’t know because the ALJ has their own schedule and they are with the Social Security Administration Our role is only to forward your case file to them. And they schedule the hearing and they also have their own schedule.

Question: So, what’s going to happen if there’s a backlog if this new decision that’s coming through for 90 days?

Answer: The Social Security Judges are taking care of what they have now, what’s happening they’re going to be different judges that they’re hiring to do the new stuff.

Question: So, it’s still could take at least a year on the old stuff?

Answer: It’s possible. Judges they just don’t do our work, they do Social Security hearings as well.

Question: Does anybody pay interest on these monies, these claims were back March or May 2004?

Answer: The only interest we will pay is if we could not get the payment to you within 30 days of receiving the judges’ decision.

Question: You talked about getting the information into you within a timely period; what about faxing the information to your area?

Answer: The judges would like to see an envelope because they want to make sure it is timely cause they give you additional information. All of the manual section we have talk about envelope – it doesn’t say we can accept the fax.

Question: So, the fax has to give you the date (the date it was faxed) right on that sheet. That’s real proof.

Answer: If it comes out. I’ve seen some faxes with nothing on the top of them. So it depends if you got your fax machine programmed for that.

Question: But if you have it, you can stamp it “Received”.

Answer: It’s always something we can try. If the judge doesn’t want to take it that, it’s up to them.

Question: Are you talking about prior to an adjudicated hearing?

Answer: Yes, this is prior to an adjudicated hearing for telephone hearing. The request has to be in writing; so we need an actual signature on those. If the fax copy is accepted? It’s like a copy. It’s not a real signature. A lot of legal aspects do accept a fax and then we do get the actual paper, but then they do accept fax as a legal document. Yes, additional documentations, we do accept as fax.

Question: I have two forms with me, the CMS 20027 form (the redetermination request form) and the other form I have is CMS 20033 (the reconsideration request form) I got them off from the website. Need clarification as to when you received reconsideration form, I’m fairly clear about the redetermination form. Maybe you could when you use those two forms; what the difference is between reconsideration and redetermination form?

Answer: The 20033 Reconsideration request form is a Part A form. That’s not designed for Part B services or to be submitted to the Part B carrier.

Question: So, I don’t use that . .. I won’t be using that at all.

Answer: Exactly. And 20027 form replaces form CMS 1964.

Question: Readjustment and re-opening is considered basically the same?

Answer: Yes it’s the same thing. (If it’s no longer reviewed is a Redetermination).

Question: Wanted to clarify which address to mail the re-determinations to? We have the zip and the mailing address as one for Appeals; and a P. O. one for Correspondence, or does it go back to the normal claims address?

Answer: On the website, when you click on contacts, today it still says “Appeals” address. If you’re going to have a re-opening however, you’re going to select the “Correspondence” address.

Question: So what’s for “re-determinations”, is it at the Correspondence address as well?

Answer: No, that is the Appeals address.

Question: And also is there a place/written on the Web where we could find all these written instructions/definitions that we can print out for the office to have on hand?

Answer: There are several Medlearn matters that are posted on our website. We have a lot of information in the Medlearn articles that actually address the correction of minor errors and omissions. It’s the number E0420. However, if you were to in our most recent visit in CA, in our 2005 workshop, in that workbook that is available out there in our publications on our website. We also have the Appeals process mapped out in that booklet. So you can use that as a source as well.

Question: But there’s nothing in the website that has at all concise in one spot?

Answer: We’re going to make sure that we put that out there for you. That’s on our “to-do” list.

Question: Ok, as far as customer service, what basically we’ll be calling customer service for the difference between the redetermination or re-opening and appeals. What does Customer Service handle?

Answer: They would handle anything like the Carrier error, billing error, or a re-opening.

Question: What is the response time if you’re sending something in to written inquiries?

Answer: It’s 45 days.

Question: Combining claims for a hearing to the hundred dollar limit or the $100.00 minimum. When you were talking about it, you actually said something about a three claim or a three-beneficiary minimum as well. Can you just go over that again?

Answer: The amount of money that is involved is a $100.00 limit in controversy did not pertain to the number of beneficiary claims. So if you had one beneficiary that had an amount of controversy of $50.00 and you had additional redetermination that you’d like to have considered, to meet that one $100.00 limit, you could combine them provided they’re still within the six months. The Telephone Appeals had two different numbers. The number of re-determinations that will take place over the telephone or ICNs have been reduced from 5 to 3. But with regards to the Hearing, it’s no more than three telephone hearing of beneficiaries at a time.

posted 7/21/05; updated 11/10/05