Requests for Reconsideration - (Rev. 4, 07-18-03)

7410 - Requests for Reconsideration - (Rev. 4, 07-18-03) A. Right to Request Reconsideration A beneficiary, provider, or practitioner (including a practitioner who does not accept assignment) may request a reconsideration regardless of whether there is a dollar amount in controversy (e.g., a party may request a reconsideration when a case is paid under the limitation on liability provision) (See 42 CFR 478.16). NOTE: The term "party" is used throughout this chapter to mean a person (or group) involved in a legal proceeding, usually the beneficiary, provider, and practitioner. A beneficiary, provider, or practitioner dissatisfied with your denial determination may obtain a reconsideration of the following issues:  Reasonableness, medical necessity (including the need for using assistants at cataract surgery), and appropriateness of the services furnished or proposed to be furnished (e.g., whether treatment was appropriate for the condition) (See §1862(a)(1) or (9) and §1154(a)(1)(A) of the Act);  Appropriateness of the setting in which the services were, or are proposed, to be furnished (See §1154(a)(1)(c) of the Act); and  Whether financially liable under §1879 of the Act (Limitation on Liability): • If the beneficiary (or the provider or practitioner) has been found liable by you, the beneficiary may obtain a reconsideration of the liability determination; • If the provider or practitioner has been found liable, or the beneficiary has been found liable but does not pursue a reconsideration on the issue of knowledge, the provider or practitioner may obtain a reconsideration of the liability determination; and • If the practitioner has been found liable and the beneficiary has been found not liable, or the beneficiary has been found liable but does not pursue a reconsideration on the issue of knowledge, the practitioner may ask for a reconsideration on the issue that neither the beneficiary nor the practitioner knew and could not have known that the services denied were not covered under Medicare Part B. NOTE: When a reconsideration is conducted, make a determination on the issue of knowledge. Providers/practitioners can only appeal the limitation on liability determination, not the medical necessity determination, beyond the reconsideration. A provider dissatisfied with your denial determination may obtain a reconsideration of a Part A denial for circumvention of PPS as specified in §7440. B. Timeframes To Request Reconsiderations  Reconsiderations of Retrospective Initial Denials -- A beneficiary who is dissatisfied with your initial denial determination may request a reconsideration by writing to you, a SSA District Office, or a Railroad Retirement Board Office (if the party is a railroad retirement beneficiary). A provider or practitioner may request a reconsideration by writing to you. Reconsider an initial denial determination if the beneficiary, provider, or practitioner files a timely written request: • Within 60 calendar days after receipt of the initial denial notice (except for a request for expedited reconsideration under 42 CFR 478.18(c)). Receipt of the notice is assumed to be within 5 days of the date of the initial notice if absent proof to the contrary (See 42 CFR 478); or • After 60 days, for good cause (See §7410.C).  Expedited Reconsiderations of Preadmission/Pre-procedure (Including Assistant at Cataract Surgery) Initial Denials -- A beneficiary, provider, or practitioner who is dissatisfied with your initial denial determination may request an expedited reconsideration by writing or telephoning you. Reconsider an initial denial determination if the beneficiary, provider, or practitioner files a timely written or telephone-expedited request within 3 calendar days after the date of receipt of the notice of a preadmission/pre-procedure (including an assistant at cataract surgery) denial. If an expedited reconsideration is not filed timely, a non-expedited reconsideration may still be requested (See §7410.B.1).  Expedited Reconsiderations of Concurrent Initial Denials -- A beneficiary, provider, or practitioner who is dissatisfied with your initial denial determination may request an expedited reconsideration through the hospital or by writing or telephoning you. Reconsider an initial denial determination if the beneficiary, provider, or practitioner files a timely expedited request at any time while the beneficiary remains in the hospital. If an expedited reconsideration is not filed timely, a non-expedited reconsideration may still be requested (See §7410.B.1). C. Good Cause for Late Filing of a Request for a Reconsideration In determining whether a party has shown that it had good cause for not filing a timely request for reconsideration, consider, but do not limit your consideration to:  The circumstances that kept a party from making the request on time;  Whether your action(s) misled a party; and  Whether a party did not understand the requirements for filing a timely request. Examples of circumstances for which you may find good cause include:  A party was seriously ill and was prevented from requesting a reconsideration;  There was a death or serious illness in a party's immediate family;  Important records were accidentally destroyed or damaged;  A party made a diligent effort, but could not find or obtain the necessary relevant information to support approval of the medical services before the deadline for requesting reconsideration;  A party requested within the applicable time limit additional information from you explaining the action, and requested reconsideration within 60 calendar days of receiving that information;  The party was given incorrect or incomplete information by you about when and how to request a reconsideration;  A party sent the request within the time limit in good faith to another Government agency, but the request did not reach the authorized office until after the time period had expired; or  Other unusual or unavoidable circumstances that show that a party could not have known of the need to file timely or that prevented the party from filing timely.