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Original Medicare (Fee-for-service) Appeals

What’s New

10/22/2018: Given the strong support from the supplier community and the initial success of the Demonstration, CMS is expanding the Demonstration into DME MAC Jurisdictions A and B. Effective on or after November 1, 2018, the DME QIC will offer telephone discussions and/or reopenings to DME suppliers within DME MAC Jurisdictions A and B for all DME claim types, except claims for glucose/diabetic testing strip supplies and claims or suppliers that are already involved in another CMS initiative (e.g., Prior Authorization for Power Mobility Devices (PMDs), Settlement Conference Facilitation (SCF), etc.). If selected and offered a telephone discussion, supplier participation remains voluntary under the expanded Demonstration. Current Demonstration activities conducted within DME MAC Jurisdictions C and D will continue as is (i.e., all DME claims types will remain eligible for telephone discussions and/or reopenings and the exclusion of glucose/diabetic testing strip supplies does not apply). 

CMS also plans to expand the Demonstration into the Part A East QIC Jurisdiction. The Part A expansion effort is still under development and an additional announcement with implementation timeframes will be forthcoming. 

01/04/2018 – CMS posts detailed information on the Low Volume Appeals Initiative.  For more details go to go.cms.gov/LVA

11/03/2017 -  As part of the broader Department of Health & Human Services commitment to improving the Medicare appeals process, CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.

The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined, as of November 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met. CMS will settle eligible appeals at 62% of the net allowed amount.

Separately, OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA option. More information will be available on the OMHA website at https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlement-conference-facilitation/index.html.

Please continue to monitor these websites for specific details about these options in the coming weeks.

11/02/2017: CMS has implemented changes to improve the processing and adjudication of Medicare Fee-For-Service (FFS) recurring (or serial) claims for capped rental items and certain Inexpensive and Routinely Purchased (IRP) items. For more information see the Medicare Learning Network article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17010.pdf

Overview - Standard Appeals Process

Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and suppliers – or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision. For more information on who is a party, see 42 CFR 405.906.

Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B).

There are five levels in the Medicare Part A and Part B appeals process. The levels are:

  1. First Level of Appeal:        Redetermination by a Medicare Administrative Contractor (MAC)
  2. Second Level of Appeal:   Reconsideration by a Qualified Independent Contractor (QIC)
  3. Third Level of Appeal:       Decision by the Office of Medicare Hearings and Appeals (OMHA)
  4. Fourth Level of Appeal:     Review by the Medicare Appeals Council
  5. Fifth Level of Appeal:        Judicial Review in Federal District Court

For detailed information about each level of appeal, use the navigation bar on the left side of this page. A downloadable brochure from the Medicare Learning Network (MLN) designed as a quick reference to the claims appeals process for providers, physicians, and other suppliers can be found in the "Related Links" section below.  To see a diagram (flowchart) of the original Medicare (fee-for-service) standard and expedited appeals process, go to the "Downloads" section below.

Appointment of Representative

A party may appoint any individual, including an attorney, to act as his or her representative during the processing of a claim(s) and /or any claim appeals.  A representative may be appointed at any time during the appeals process.  

There are 2 ways that a party can appoint a representative:

  1. Fill out the Appointment of Representative Form (CMS-1696; a link to this form can be found in the "Related Links" section below); or
  2. Create a written notice containing all of the elements listed in 42 CFR 405.910.  

The appointment of representative is valid for one year from the date it contains the signatures of both the party and the appointed representative.  A valid appointment of representative may be used multiple times to initiate new appeals on behalf of the party, unless the party provides a written statement of revocation of the representative’s authority. The appointment remains valid for any subsequent levels of appeal on the item/service in question unless the party specifically withdraws the representative’s authority. A detailed explanation on appointing a representative can also be found in the Medicare Claims Processing Manual Publication 100-4, chapter 29, section 270.

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices caring for beneficiaries enrolled in Original Medicare are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end before they have finished providing them. Hospitals are also required to notify hospitalized inpatient Original Medicare beneficiaries of their hospital discharge appeal rights and their right to appeal a discharge decision.

For detailed information about the expedited determination appeals process, see the CMS.gov Expedited Determination Beneficiary Notices webpage sections at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices.html. For information on hospital discharge appeal rights, refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html. Applicable regulations can be found at 42 CFR 405 Subpart J—Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges.

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

Demonstration Background:

On January 01, 2016, CMS launched 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 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 Administrative Law Judge (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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