100-04 Medicare Claims Processing Manual: Chapter 29 Crosswalk
us-cms-medicare-manuals-pub-100-04-clm104c29crosswalk100-04 Medicare Claims Processing Manual: Chapter 29 CrosswalkGuidance
Medicare Claims Processing Manual Chapter 29 - Appeals of Claim Decisions Crosswalk Note: QIO appeals instructions are to remain in the QIO Manual. Some background material is repeated here to enhance understanding. Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 01 Foreword 29 10 3790 12000 600 287 256 380 408 628 QIO-740 CMS Decisions Subject to the Administrative Appeals Process 29 20 3780 12000 600 287.4 256 383 408 628 QIO-740 Who may Appeal 29 30 600 287 383 628 Where to Appeal 29 30.1 600B Social Security Office (SSO) 29 30.2 Part A Intermediary (FI) 29 30.2.1 FI Initial Determinations with Respect to Beneficiaries 29 30.2.2 Provider's Right to Appeal Certain Initial Determinations 29 30.2.3 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 30.3 12000 Part B Carrier 29 30.4 QIO-7400 Quality Improvement Organization (QIO) 29 30.4.1 QIO-7400 QIO Reconsiderations and Appeals
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 30.5 HMO-2403 Health Maintenance Organizations (HMO) and Managed Care + Choice Organizations 29 30.6 RO-3600 CMS Regional Office Responsibility 29 30.6.1 RO-3600 Assisting FIs to Obtain Documentation 29 30.6.2 RO-3610 Congressional Requests for Part A Reconsideration 29 30.7 PM-AB-02-111 Time Limits for Filing Appeals 29 30.8 PM-AB-02-111 Amount In Controversy Requirements 29 40 3781 287.4 257 383A 628A PM-AB-00-122 Part A Appeals Procedures 29 40.1 3781 Initial Determinations 29 40.1.1 3781.1 Initial Determinations With Respect to Beneficiaries 29 40.1.2 3781.2 287.2 381 Provider's Right to Appeal Certain Initial Determinations 29 40.1.3 3781.3 287.3 382 Situations Where Provider May Initiate Appeal 29 40.1.4 3781.4 Appeals That Involve an Adverse Utilization Review Committee (URC) Decision 29 40.1.5 3781.6 Finding Good Cause for the Late Filing of Appeal Requests 29 40.1.5.1 3781.6A General 29 40.1.5.2 3781.6B Establishment of Time Limit for Filing 29 40.1.5.3 3781.6C Conditions Which Establish Good Cause 29 40.1.5.4 3781.6D Procedure to Establish Good Cause 29 40.1.5.5 3781.6E Examples of Situations Where Good Cause Exists 29 40.1.5.6 3781.6F Where Good Cause Is Not Found
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 40.1.6 3781.7 Assisting Handicapped Beneficiaries 29 40.2 3782 Reconsideration of a Part A Payment Determination 29 40.2.1 3782.1 Place and Manner of Filing Requests for Reconsideration 29 40.2.2 3782.2 Completing Form CMS-2649, Request for Reconsideration of Part A Health Insurance Benefits 29 40.2.3 3782.3 Routing the Reconsideration Request 29 40.2.4 3782.4 Acknowledging Receipt 29 40.2.5 3782.5 Transferring and Dismissing Requests Which Involve Partial or No Jurisdiction, More Than One Component, Stay, or Issue 29 40.2.6 3782.7 Handling of Request--Beneficiary Appeals Before Initial Determination Is Made or After Initial Favorable Determination Is Made, But Before They Are Notified 29 40.2.7 3782.8 Withdrawal of Request 29 40.2.8 3782.9 Notifying Provider or Beneficiary Where There Is a Withdrawal 29 40.3 3783 Documenting Part A Reconsideration Requests 29 40.3.1 3783.1 Documentation Sources 29 40.3.2 3783.2 Assembling the File 29 40.3.3 3783.3 PM-AB-00-122 Development 29 40.4 3784 Evaluating the Evidence and Making the Reconsideration Determination 29 40.4.1 3784.1 Evaluating the Evidence
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 40.4.2 3784.2 Review Prior to Reversal of Initial Payment Determination 29 40.4.3 3784.3 AB-90-12 Preparing the Determination 29 40.4.4 3784.4 Completing the Determination 29 40.4.5 3784.5 Notice of Further Appeal Rights 29 40.4.6 3784.6 Preventing Duplicate Payment in Reversal Cases 29 40.4.7 3784.7 Effect of a Reconsideration Determination and Effectuation 29 40.4.7.1 PM-A-00-32 Effectuating Favorable Final Appellate Decisions That a Beneficiary is “Confined to Home” – Regional Home Health Intermediaries (RHHIs) Only 29 40.4.8 3784.9 Reconsideration Guide Language 29 40.4.8.1 PM-A-01-21 Sample Paragraphs to Be Used by FIs in Sequence as Shown below 29 40.5 3785 Request for Hearing under Part A 29 40.5.1 3785.1 Determining The Amount In Controversy 29 40.5.2 3785.2 Request Filed With SSO 29 40.5.3 3785.3 Request For Hearing Filed With The FI 29 40.5.4 3785.4 Request For Hearings FIs Receive Pertaining To QIO or HMO 29 40.5.4.1 3785.4 Request For Hearings FIs Receive Pertaining To QIO 29 40.5.4.2 3785.4 Request For Hearings FIs Receive Pertaining To HMO 29 40.5.5 3785.5 Action On Incoming Requests
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 40.5.6 3785.6 Request For Claim File (Sent By Hearing Office) 29 40.5.7 3785.7 Examination Of Claim File 29 40.5.8 3785.8 Prehearing Case Review 29 40.5.9 3785.9 Routing The Hearing Claim File 29 40.5.10 3785.10 Standard Exhibits Referred To In §§40.50-40.50.9 29 40.6 3786 Scope and Effect of OHA, SSA Administrative Law Judge (ALJ) Decisions under Part A 29 40.7 3787 Effectuation of Reversal of Decision Where There Was Subsequent Utilization of Benefits in the Same Benefit Period 29 40.8 3788 Effect of Court Decisions 29 40.9 12019 Right to Representation Under Part A 29 40.10 3790 Reconsiderations, Hearings, and Appeals Where a QIO Has Review Responsibility 29 40.10.1 3790.1 Reconsiderations 29 40.10.2 3790.3 Hearings 29 40.10.3 Appeals of Institutional Supplementary Medical Insurance (Part B) Claim Decisions 29 40.11 3798 287.5 Appeals by Hospitals of Diagnosis-related Group (DRG) Assignments under PPS 29 50 Part B Appeals Procedures - FIs 29 50.1 3791 FI - Review, And Fair Hearing - Supplemental Medical Insurance 29 50.2 3792 Extension Of Time Limit For Filing An Appeal
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 50.3 3793 Review 29 50.3.1 3793.1 What Constitutes a Request for Review - Handling Beneficiary Inquiries 29 50.3.2 3793.2 Elements of a Review 29 50.3.3 3793.3 Actions Prior to Reversal of Initial Payment Decision 29 50.4 3794 The Hearing 29 50.4.1 3794.1 Types of Hearings 29 50.4.2 3794.2 Issues Determined at the Hearing 29 50.4.3 3794.3 Request for Hearing 29 50.4.4 3794.4 Hearing Officer (HO) 29 50.4.5 3794.5 Preparation for the Hearing 29 50.4.6 3794.6 Conduct of an In-Person or Telephone Hearing 29 50.4.7 3794.7 Parties to the Hearing 29 50.4.8 3794.8 In-Person and Telephone Hearing Procedures 29 50.4.9 3794.9 On The Record Decision 29 50.4.10 3794.10 Hearing Decision 29 50.4.11 3794.11 Content of Hearing Decision 29 50.4.12 3794.12 Style of Hearing Decision 29 50.4.13 3794.13 Effectuation of HO Decision 29 50.5 3795 RO Examination Of Hearing Decisions 29 50.6 3796 Fraud And Abuse
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 50.6.1 3796.1 Disclosure of Information 29 50.7 3797 Requests For Hearing Before An ALJ 29 60 12000 383B 628B Part B Appeals Procedures 29 60.1 12000.1 Initial Determination 29 60.2 12000.2 PM-AB-00-122 Steps in the Appeals Process: Overview 29 60.3 12001 FI and Carrier Correspondence With Beneficiaries Or Other Parties Regarding Appeals 29 60.4 12002 Parties To An Appeal 29 60.5 12004 Appointment Of Representative 29 60.5.1 12004.1 600 287.4B 257B 383B 628 Appointment of Representative - Introduction 29 60.5.2 12004.2 Who May Be A Representative 29 60.5.3 12004.3 How to Make and Revoke an Appointment 29 60.5.4 12004.4 When to Submit the Appointment 29 60.5.5 12004.5 Where to Submit the Appointment 29 60.5.6 12004.6 PM-B-02-074 Rights and Responsibilities of a Representative 29 60.5.7 12004.7 Validity of an Appointment Over Time 29 60.5.8 12004.8 Timeliness of an Appeal Request and Completeness of Appointment 29 60.5.9 12004.9 Powers of Attorney 29 60.5.10 12004.1 Incapacitation or Death of Beneficiary 29 60.5.11 12004.11 Disclosure of Individually Identifiable Beneficiary Information to Representative
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.6 12006 Amount In Controversy 29 60.6.1 12006.1 Amount in Controversy Defined 29 60.6.2 12006.2 Amount in Controversy General Requirements 29 60.6.3 12006.3 Calculating the Amount in Controversy 29 60.6.4 12006.4 Additional Considerations for Calculation of the Amount in Controversy 29 60.6.5 12006.5 Aggregation of Claims to Meet the Amount in Controversy 29 60.7 12008 Extension Of Time Limit For Filing A Request For Review Or Fair Hearing 29 60.7.1 12008.1 Good Cause 29 60.7.2 12008.2 General Procedure to Establish Good Cause 29 60.7.3 12008.3 Conditions that May Establish Good Cause for Late Filing by Beneficiaries 29 60.7.4 12008.4 Examples of Situations Where Good Cause for Late Filing Exists for Beneficiaries 29 60.7.5 12008.5 Conditions that May Establish Good Cause for Late Filing by Physicians or Other Suppliers 29 60.7.6 12008.6 Examples of Situations Where Good Cause for Late Filing Exists for Physician or Other Suppliers 29 60.7.7 12008.7 Good Cause Not Found for Beneficiary, or for Provider, Physician or Other Supplier 29 60.8 12009 Fraud And Abuse 29 60.8.1 12009.1 Fraud and Abuse - Authority
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.8.2 12009.2 Inclusion and Consideration of Evidence of Fraud and/or Abuse 29 60.8.3 12009.3 QIO-7560 Claims Where There Is Evidence That Items or Services Were Not Furnished, or Were Not Furnished as Billed 29 60.8.4 12009.4 Responsibilities of Reviewers and Hearing Officers 29 60.8.5 12009.5 Requests to Suspend the Appeals Process 29 60.8.6 12009.6 Continuing Appeals of Providers, Physicians or Other Suppliers Who are Under Fraud or Abuse Investigations 29 60.8.7 12009.7 Appeals of Claims Involving Excluded Providers, Physicians or Other Suppliers 29 60.9 12010 Guidelines For Writing Appeals Correspondence 29 60.9.1 12010.1 General Guidelines 29 60.9.2 12010.2 Letter Format 29 60.9.3 12010.3 Required Elements in Appeals Correspondence 29 60.10 12011 Disclosure Of Information 29 60.10.1 12011.1 General Information 29 60.10.2 12011.2 Fraud and Abuse Investigations 29 60.10.3 12011.3 Medical Consultants Used 29 60.10.4 12011.4 Multiple Beneficiaries 29 60.11 12012 Review - The First Level Of Appeal 29 60.11.1 12012.1 Filing a Request for Review 29 60.11.2 12012.2 Time Limit for Filing a Request for Review
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.11.3 12012.3 Recording of Inquiries and Other Actions on the Carrier Appeal Report (FI - Form CMS-2591, Carrier - Form CMS-2590) 29 60.11.4 12012.4 The Review 29 60.11.5 12012.5 The Review Determination 29 60.11.6 12012.6 Review Determination Letter 29 60.11.7 12012.7 Effect of the Review Determination 29 60.12 12013 Telephone Review Procedures 29 60.12.1 3795 12013.1 RO-9005.3 Informing the Beneficiary and Provider Communities about The Telephone Review Process 29 60.12.2 3796 12013.2 Issues for Telephone Reviews 29 60.12.3 3796.1 12013.3 Issues During the Telephone Review 29 60.12.4 3797 12013.4 Time Limit for Requesting a Telephone Review 29 60.12.5 12013.5 Review Requests Made on Behalf of the Party on the Telephone 29 60.12.6 3790 12013.6 QIO-7400 Conducting the Telephone Review 29 60.12.7 3790.1 12013.7 Documenting the Call 29 60.12.8 3790.2 12013.8 Timely Processing Requirements 29 60.12.9 3799 12013.9 620 288 384 630 Review Determination Letters 29 60.12.10 12013.10 Education 29 60.12.11 12013.11 Monitoring Telephone Reviews 29 60.13 12014 Fair Hearing - The Second Level Of Appeal 29 60.13.1 12014.1 Filing a Request for Fair hearing
Chap. Qualifications and General Responsibilities Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 Disqualification of HO HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.13.2 12014.2 Time Limit for Filing A Request for Fair Hearing 29 60.13.3 12014.3 Request for HO hearing Filed Prior to a Review Determination 29 60.13.4 12014.4 Exceptions to Filing Requirements 29 60.14 12016 Request For HO Hearing 29 60.14.1 12016.1 Timely Processing Requirements 29 60.14.2 12016.2 Contractor Responsibilities – General 29 60.14.3 12016.3 Requests for Transfer of In-Person Hearings 29 60.14.4 12016.4 Acknowledgment of Request for HO hearing 29 60.14.5 12016.5 Case File Development 29 60.14.6 12016.6 Case File Preparation 29 60.15 12017 Types Of Fair Hearings 29 60.15.1 12017.1 In-Person Hearing 29 60.15.2 12017.2 Telephone Hearing 29 60.15.3 12017.3 On-the-Record (OTR) Hearing and Decision 29 60.15.4 12017.4 Preliminary On-The-Record (POTR) Hearing and Decision 29 60.16 12018 Hearing Officer (HO) Authority And Responsibilities 29 60.16.1 12018.1 Hearing Officer (HO) Authority 29 60.16.2 12018.2 29 60.16.3 12018.3
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 29 OTHER 60.17 Description 12019 Fair Hearing Procedures 29 60.17.1 12019.1 Preparation for the Fair Hearing 29 60.17.2 12019.2 Scheduling the Date, Time and Place of Hearing 29 60.17.3 12019.3 Adjournment and/or Postponement of Telephone or In-person Hearing 29 60.17.4 12019.4 Pre-Hearing Review of the Evidence 29 60.17.5 12019.5 Forwarding Copy of Case File Prior to Telephone Hearing 29 60.17.6 12019.6 In-Person and Telephone HO hearing Procedures 29 60.17.7 12019.7 The Fair Decision Timeliness 29 60.18 12020 Effectuation Of Fair Hearing Decisions 29 60.18.1 12020.1 General Rule 29 60.18.2 12020.2 Delaying Effectuation 29 60.18.3 12020.3 Elements of Written Request for Reopening 29 60.18.4 12020.4 Notice to Parties of Reopening Request 29 60.18.5 12020.5 HO Reply to Reopening Request 29 60.18.6 12020.6 Notice to Parties of HO Determination 29 60.19 12026 Requests For Part B Administrative Law Judge (ALJ) Hearing 29 60.19.1 12026.1 Right to Part B ALJ Hearing 29 60.19.2 12026.2 Forwarding Requests to SSA/OHA 29 60.19.3 12026.3 Case File Preparation
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.19.4 12026.4 Acknowledgment of Request for Part B ALJ Hearing 29 60.19.5 12026.5 Model Format for Acknowledgment of ALJ Hearing Request 29 60.20 12028 Effectuation Of Part B Administrative Law Judge (ALJ) Decisions/Dismissals 29 60.20.1 12028.1 Review and Effectuation of ALJ Decisions - General 29 60.20.2 12028.2 Effectuation Time Limits 29 60.20.3 12028.3 ALJ Data Extraction Form 29 60.20.4 12028.4 Misrouted ALJ Case Files 29 60.20.5 12028.5 Duplicate ALJ Decisions 29 60.21 12029 Recommending Agency Referral Of Part B ALJ Decisions Or Dismissals To The CMS RO 29 60.21.1 12029.1 Time Limits for Forwarding Agency Referral Memorandum to CMS RO 29 60.21.2 12029.2 Guidelines for Reviewing ALJ Decisions/Dismissals 29 60.21.3 12029.3 Draft Agency Referral Memorandum Content 29 60.21.4 12029.4 Draft Memorandum Format 29 60.21.5 12029.5 Submission of Draft Agency Referral Memorandum to CMS RO 29 60.22 12032 Effectuation Of DAB Orders And Decisions 29 60.22.1 12032.1 Background 29 60.22.2 12032.2 PM-AB-01-62 Requests for Case Files 29 60.22.3 12032.3 Contractor Effectuation Responsibilities
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.22.4 Payment of Interest on DAB Decisions 29 60.23 12033 Request For U.S. District Court Review By A Party 29 60.24 12034 Effectuation Of U.S. District Court Decisions 29 60.24.1 Payment of Interest on U.S. District Court Decisions 29 60.25 12040 Review And Analysis o Initial Determinations And Appeal 29 60.27 12100 Reopening and Revision of Claims Determinations and Decisions 29 60.27.1 12100.1 Development of Appeals 29 60.27.2 12100.2 How Issues May Arise 29 60.27..3 12100.3 Summary of Conditions Under Which a Determination or Decision May Be Reopened 29 60.27.4 12100.4 Determining Date of Initial or Reviewed Determination, or HO's Decision 29 60.27.5 12100.5 Who May Reopen an Initial or Reviewed Determination or HO's Decision 29 60.27.6 12100.6 Actions to Permit Reopening Within the l-Year or 4- Year Period 29 60.27.7 12100.7 Good Cause for Reopening 29 60.27.8 12100.8 Definitions 29 60.27.9 12100.9 Unrestricted Reopening 29 60.27.10 12100.10 Reopening an Initial Decision 29 60.27.11 12100.11 Reopening a Review Determination
Chap. Sect Int. Pub.13-3 Carrier Pub.14-3 OPT Pub. 09 HO Pub. 10 HH Pub. 11 SNF Pub. 12 HSP Pub. 21 RHC Pub. 27 OTHER Description 29 60.27.12 12100.12 Reopening a Fair Hearing Decision 29 60.27.13 12100.13 Notice of Results of Reopening 29 60.27.14 12100.14 Exception to Sending Notice of Revision to Parties-- Cases Involving Limitation on Recovery from Beneficiary 29 60.27.15 12100.15 Refusal to Reopen Is Not an "Initial Determination" 29 60.27.16 12100.16 Revised Determination or Decision 29 60.28 12999 List of Exhibits 29 70 12900 Glossary
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