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Second Level of Appeal: Reconsideration by a Qualified Independent Contractor

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

Requesting a Reconsideration

The appellant (the individual filing the appeal) has 180 days from the date of receipt of the redetermination decision to file a reconsideration request. The redetermination decision can be communicated through a Medicare Redetermination Notice (MRN), a Medicare Summary Notice (MSN), or a Remittance Advice (RA). The redetermination decision is presumed to be received 5 days after the date on the notice unless there is evidence to the contrary. 

A reconsideration must be requested in writing. Instructions for filing a reconsideration request are on the MRN, and can also be found on the website of the Medicare Administrative Contractor (MAC) that issued the redetermination. A list of MAC websites and contact information can be found at: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#MapsandLists 

A reconsideration request can be filed using either:

  1. The form CMS-20033 (available in “Downloads below), or
  2. Send a written request containing all of the following information:
    • Beneficiary's name
    • Beneficiary's Medicare number
    • Specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service
    • Name and signature of the party or the authorized or appointed representative of the party
    • Name of the contractor that made the redetermination
    • Any missing documentation identified in the notice of redetermination

The request should clearly explain why the appellant disagrees with the redetermination, and be accompanied by any evidence or allegations of fact or law related to the issue(s) in dispute. A copy of the MRN or RA, and any other relevant documentation, should be sent with the reconsideration request to the appropriate QIC. A minimum monetary threshold is not required to request a reconsideration.

Documentation that is submitted after the reconsideration request has been filed may result in an extension of the timeframe a QIC has to complete its decision. This does not apply to timely submission of documentation requested by the QIC. It is not necessary to resubmit information that was already submitted to the MAC. Any documentation not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless good cause is shown for not submitting the documentation previously.

QIC Review of a Dismissal of a Redetermination Request

If a MAC has dismissed a redetermination request, any party to the redetermination has the right to appeal a dismissal of a redetermination request to a QIC if they believe the dismissal is incorrect. The request for review must be filed with the QIC within 60 days after the date of receipt of the dismissal. When the QIC performs its review of the dismissal, it will only decide on whether or not the dismissal was correct. If it determines that the MAC incorrectly dismissed the redetermination, it will vacate the dismissal and remand the case to the MAC for a redetermination. See “First Level of Appeal” webpage (left navigation bar) for more information on MAC dismissals.

NOTE: A QIC’s action after review of a MAC’s dismissal of a redetermination request is binding and not subject to any further review or appeal.

Dismissal of a Reconsideration Request

A QIC may dismiss a reconsideration request in the following instances:

  1. If the party (or appointed representative) requests to withdraw the appeal; or
  2. If there are certain defects, such as
    1. The party fails to file the request within the appropriate timeframe and did not show (or the QIC did not accept) good cause for late filing
    2. The representative is not appointed properly
    3. The requestor is not a proper party

Detailed information on QIC dismissals can be found at 42 CFR 405.972.

Parties to a QIC's dismissal of a request for reconsideration have 2 options if they disagree with the dismissal:

  1. Request review of the dismissal by an Administrative Law Judge (ALJ,) or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA)
  2. Request that the QIC vacate the dismissal

 

OMHA Review of the Dismissal

QIC Vacate the Dismissal

Filing Timeframe

60 days after dismissal receipt

6 months after dismissal mailed

Minimum Amount in Controversy Required?

YES

NO

Review Criteria

Is dismissal correct?

Is there good and sufficient cause to vacate dismissal?

Course of Action

Vacate dismissal and remand case to QIC for reconsideration

Vacate dismissal and issue reconsideration decision

Subject to Further Review?

NO

NO

Reconsideration Decision Notification

The reconsideration decision will contain detailed information on further appeals rights, where applicable. Generally, the QIC will send this decision to all parties within 60 days of receipt of the request for reconsideration. If the QIC is unable to complete its reconsideration within this timeframe (with exceptions for extensions for additional evidence submissions and late filing), the QIC must send a notice to the parties and advise the appellant of the right to escalate the appeal to OMHA. If the party chooses to escalate the appeal to OMHA, a written request must be filed with the QIC in accordance with instructions on the escalation notice.

Fact Sheet: Reconsideration Appeals Data

These reports summarize and highlight some of the key data on reconsiderations from January 1, 2009 through December 31, 2017.  To view the Appeals Fact Sheets, click on the link in the "Downloads" section below.

Original Medicare (Fee-For-Service) Qualified Independent Contractors

The following is a list of the QICs and the jurisdictions that they serve:                                        

Maps of the QIC jurisdictions, mailing addresses and website information for all QICs are available in “Downloads” under "QIC Maps."

Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration

Demonstration Background:

On January 01, 2016, CMS launched a the QIC Telephone Discussion and Reopening Process Demonstration to test whether further engagement between Durable Medical Equipment (DME) suppliers and the DME QIC will improve the understanding of the cause of appeal denials, and over time, result in more proper claim submission at the DME MAC level from suppliers participating in the Demonstration. The Demonstration initially focused on oxygen and glucose/diabetic testing strip supplies. However, on October 1, 2016, CMS expanded the Demonstration to include all DME claim types within DME MAC Jurisdictions C and D, with exception to claims or suppliers that were already subject to another Centers for Medicare & Medicaid Services (CMS) initiative (e.g., Prior Authorization for Power Mobility Devices (PMDs), Settlement Conference Facilitation (SCF)).

Under the Demonstration, the QIC reviews reconsideration requests to identify appeals that may benefit from participation in the telephone discussion process. Eligible DME suppliers are offered the opportunity to engage in a recorded telephone discussion of appealed claims with the DME QIC prior to the issuance of the reconsideration decision. Participation in the telephone discussion is voluntary. The telephone discussion process allows suppliers to discuss the facts of the case with the QIC and to submit any missing/critical documentation identified by the QIC, as needed, to support a favorable resolution, prior to the DME QIC rendering a decision. This process also works to educate the supplier community on Medicare coverage policies, the root causes of denials, and any trends associated with documents that are critical to the outcome of an appeal.

As part of the Demonstration, the DME QIC is also conducting analysis on previously completed unfavorable reconsideration decisions dated on or after January 1, 2013, to identify potential appeals that can now be resolved favorably through the reopening process. Under this Demonstration, the QIC has the authority to conduct reopenings on previously adjudicated unfavorable claims that are currently pending ALJ assignment at OMHA, and/or unfavorable reconsiderations that have been decided by the QIC, but not yet appealed to OMHA. Further, the DME QIC assists suppliers in submitting withdrawal requests to OMHA when, through the course of the Demonstration activities, the supplier determines that they no longer wish to continue pursuing appeal(s) currently pending at OMHA.

For more information on this Demonstration, see the link to “Formal Telephone Demonstration Fact Sheet 2016” in the Related Links section below.

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