Appeals Resulting from RAC Initiated Denials

9.7 – Appeals Resulting from RAC Initiated Denials (Rev. 921, Issued: 11-06-19 Effective: 11-04- 19, Implementation: 11-04-19) The MACs shall process any appeals stemming from a RAC improper payment (e.g. RAC decisions appealed by the providers or beneficiaries) as any other appeal request. Upon receiving an appeal request for a RAC improper payment, the MAC shall request the medical records and any other supporting documentation from the RAC. The timeframes regarding requesting and receiving medical records from the RAC shall be agreed upon in the JOA. Even if the MAC believes they have enough documentation to make a determination on the appeal, the MAC shall still request the medical records and any other supporting documentation, as providers may submit different documentation to the RAC than to the MAC upon appeal. The MAC shall utilize the same approach in denying an appeal request (i.e. reopening or redetermination) as used with any other appeal request. For more information on to determine whether an appeal request should be processed as a reopening or redetermination, MACs shall refer to the Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 34, Section 10.