Reconsideration Process - (Rev. 4, 07-18-03)

7430 - Reconsideration Process - (Rev. 4, 07-18-03) A. Provision of Information to Parties Prior to the reconsideration, give all parties, upon request, an opportunity to examine or obtain a copy of all the material upon which the initial denial determination was based, including the complete medical record and summary of your findings and conclusions in making the initial denial determination. Inform the requester that he may have to pay a reasonable fee for the redaction of, reproduction of, and postage for, the material requested (If patient information would be harmful to the beneficiary, provide it to the beneficiary's designated representative upon receiving the request in writing pursuant to 42 CFR 480.132(c)). In accordance with regulations governing disclosure of confidential QIO information and regulations at 42 CFR 478.24(a), do not give a party access to:  Your deliberations; and  The identity of your review coordinators, physician advisors, or consultants that assisted in reviewing the case (unless they have consented to release of their names). Establish and implement procedures to segregate your deliberations and identifiers from the medical records when redacting. No document or other information produced by you in connection with your deliberations in making reconsiderations under Title XI of the Act shall be subject to subpoena or discovery in any administrative or civil proceeding, except that you shall provide, upon request of a practitioner or other person adversely affected by such a determination, a summary of the organization's findings and conclusions in making the determination (See §1160(d) of the Act). B. Provision For Submittal of Additional Information from Parties Give all parties the opportunity to present additional documentary materials (e.g., new evidence) for consideration. C. The Reconsideration Proceedings Conduct the reconsideration proceedings as spelled out in your contract with CMS. Conduct a medical records review at your office with no party being present, or conduct proceedings similar to an evidentiary hearing. In either case, give the party advance notice of the date of the reconsideration to allow sufficient time for submission of evidence. Reschedule a reconsideration if a party submits a written request presenting reasonable justification for rescheduling. If your contract calls for an evidentiary hearing:  Give any party the opportunity to ask reasonable questions (e.g., to clarify information presented) of you or of any person who gives testimony; and  Do not deny any involved party access to the hearing either while you present information or while another party (or a witness) presents information. You are not required to have your legal counsel attend even if legal counsel for a party attends. In addition, you are not required to make a transcript of the reconsideration proceedings. A summary of the proceedings is adequate. D. Evidence at Reconsideration Consider all information in the medical record, the basis for the initial determination, and any additional evidence submitted by a party. E. Areas of Consideration Make a determination on medical necessity, reasonableness and appropriateness of setting, and whether the beneficiary/physician/provider knew or should have known that the care in question was not covered. F. Timing of the Reconsidered Determination Complete your reconsidered determination and send written notice within the timeframes that follow:  For preadmission or pre-procedure or assistant at cataract surgery reviews, within 3 working days after you receive the reconsideration request. Apply this timeframe if the initial denial determination was made before the beneficiary was admitted to the institution or before surgery was performed and a timely expedited reconsideration request was made (see §7410.B.2).  When the beneficiary is a hospital inpatient, within 3 working days after you receive the reconsideration request. Apply this timeframe if the initial denial determination was made while the beneficiary was still in the hospital and a timely expedited reconsideration request was made (See §7410.B.3).  When the beneficiary is an inpatient in a SNF or receiving home health agency (HHA) services, within 10 working days after you receive the reconsideration request. Apply this timeframe if the beneficiary is still an inpatient in a SNF for the stay in question or is receiving home health services for the stay in question when you receive the request.  When the beneficiary is receiving non-institutional services, is no longer an inpatient, or does not file a timely expedited request, within 30 working days after you receive the reconsideration request. Apply this timeframe if the initial denial determination concerns ambulatory or non-institutional services (except pre- procedure reviews), the beneficiary is no longer an inpatient in a hospital or SNF and is not receiving home health services for the stay in question, or the party does not file a timely request for expedited reconsideration (see §§7410.B.1 and 2). Maintain a system, such as a log, for documenting your receipt of the request for reconsideration. Receipt, unless otherwise proven, means the day that you have in your records documentation that a notice was received. A party may request additional information to further explain the determination within 30 working days, and may request a reconsideration within 60 days of receiving the explanation (or within 30 days for an Appeals Council hearing). G. Notices of a Reconsideration Determination Notices to Parties -- Notify all parties in writing of your reconsidered determination. Discuss in detail the reasons for the initial and reconsidered determinations. Ensure that the appellant understands the reason(s) for your determination and provide support for your determination should the case be heard by an ALJ. NOTE: Do not send beneficiaries or physicians reconsideration notices for circumvention of PPS (See §7440 for further instructions for processing circumvention of PPS reconsiderations). All reconsideration notices must contain the following elements unless otherwise specified (see Exhibits 7-40 through 7-50):  A brief statement concerning your duties and functions under the Act (Cite the regulatory basis for your review authority);  The date that the reconsideration was requested and the party who requested it;  The date of the admission or procedure, the name of the provider, and the reason for the admission or the name of the procedure furnished;  A detailed explanation of the reason for the initial denial determination. A statement that the care was not medically necessary is not an adequate explanation (see §7115.C.5);  The qualifications of the physician(s) who reviewed the case at the reconsideration level in a manner consistent with your disclosure requirements;  A brief statement explaining that the provider and practitioner were given an opportunity to provide additional information;  A clear explanation of the reasons for the reconsidered determination, including a narrative description of the medical facts and a detailed rationale for the determination. Provide the appropriate statutory and regulatory citations. Include an evaluation of any new points raised as part of the reconsideration request. If no new points are raised, state this in your notice;  A statement about each party's liability for payment. State the initial liability determination for each party, including the rationale for each liability determination. State the reconsidered determination for each party. Provide a clear discussion of the Medicare payment consequences of the reconsidered determination for the beneficiary, provider, and/or physician, including the rationale for the liability determination;  Fully document your determination that the beneficiary/provider/practitioner knew or should have known that the care in question was not covered. The following are examples of rationales that would support your liability determination (see 42 CFR 411.406, §§7115.C.6 and 7): • The beneficiary received written notice from you, the fiscal intermediary (FI), carrier, utilization review committee, provider, or physician that the services were not covered or that similar or reasonably comparable services were not covered. Include a copy of the written notice in the reconsideration notice; and • The provider and/or physician had prior knowledge that the services furnished were not covered or that similar or reasonably comparable services were not covered based on experience, actual notice, or constructive notice. This knowledge is based upon the provider's receipt of CMS/QIO/FI/carrier notices (such as manual issuances, bulletins, or other written guides or directives), medical review screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue, or the provider's knowledge of what are considered acceptable standards of practice by the local medical community. Provide specific references and dates in the provider's and physician's rationale (e.g., Bulletin #200, issued September 30, 1990).  For denials based on circumvention of PPS, explain that the limitation on liability provisions under §1879 do not apply, that the hospital is liable for the denied charges, and that the beneficiary or his/her representative is only responsible for payment of any applicable amounts for deductible, coinsurance, and convenience services and items normally not covered by Medicare (see Exhibit 7-50);  A statement regarding the indemnification of the beneficiary for provider and/or physician services when the beneficiary has been found not liable (see §§7115C.8 and 9) (Include only if the initial denial is upheld or partially reversed. Do not include in circumvention of PPS denials);  If the beneficiary, provider, and/or physician has been found not liable, specify that the beneficiary is responsible only for payment of any deductible, coinsurance, and convenience services and items normally not covered by Medicare for the denied period;  If the provider and/or physician has been found liable and the beneficiary has been found not liable, specify that the beneficiary is responsible only for payment of any convenience services and items normally not covered by Medicare for the denied period;  Include the name, address, and telephone number of the FI and/or carrier where the beneficiary can file a request for indemnification;  Inform the beneficiary that if a request for indemnification is filed, a copy of the denial notice, a copy of the bill for services, and a copy of the payment receipt from the provider or any other evidence showing that the beneficiary paid the provider must be provided to the FI or carrier;  A statement regarding future liability (See §7115.C.10) (Include only if the initial denial is upheld or partially reversed. Do not include in circumvention of PPS denials);  A complete discussion about further appeal rights of all parties (i.e., right to request a hearing before an ALJ) (Include only if the initial denial is upheld or partially reversed);  Make it clear that beneficiaries may appeal the reasonableness, medical necessity, or appropriateness of services furnished or proposed to be furnished, the appropriateness of the setting in which the services were or are proposed to be furnished, or whether they are liable for payment under §1879 of the Act (Limitation on Liability). The provider and physician may only request a hearing on the issue of knowledge under §1879. Providers may request a hearing on the issue of circumvention of PPS (see §7410.A);  State the minimum amount that must be in controversy to appeal your reconsideration determination (see §7500);  State that a written request for appeals (ALJ hearings) must be filed within 60 calendar days after receipt of a reconsideration determination;  State that the request should include: the beneficiary's name, Medicare health insurance claim number, where and when the services were received, the reason for dissatisfaction with your determination, any additional evidence the beneficiary, provider or physician wishes to submit, and a copy of the reconsideration notice;  State that a beneficiary may send an ALJ hearing request to you, any SSA District Office, any Office of Hearings and Appeals (OHA), or a Railroad Retirement Board Office (if eligible) and that a provider or practitioner may send an ALJ hearing request to you or OHA (Do not include in circumvention of PPS denials);  A statement regarding the beneficiary's or his/her representative's right to legal representation (Include only if the initial denial is upheld or partially reversed. Do not include in circumvention of PPS denials). Use the following language without alteration: • "If you want help with your appeal of this denial determination, you can have a friend, lawyer or someone else help you. Some lawyers do not charge unless you win your appeal. There are groups, such as lawyer referral services, that can help you find a lawyer. There are also groups, such as legal aid services, who will give you free legal services if you qualify."  A statement regarding the beneficiary's or his/her representative's right to examine or receive a copy of the complete medical/clinical record (Include only if the initial denial is upheld or partially reversed. Do not include in circumvention of PPS denials). Use the following language without alteration: • "You have the right to examine the complete medical record (and other pertinent information) that we relied upon in making this denial determination. Although the hospital is the official repository of the medical records relevant to stays in the facility, should you wish to examine the records and other pertinent information for this particular stay, contact us at the address or telephone number listed above. There is no charge to examine the material at our office. You may also request a copy of the medical record and other pertinent information. We will, however, charge you a reasonable fee for photocopying and mailing this information."  The signature of the medical director or designated physician (see §7115.C.15). Notice to Payers -- Provide prompt written or electronic notification to the appropriate Medicare FI or carrier of a reconsidered determination when the initial denial and/or liability determination is partially or totally reversed. Include the name of the beneficiary, the health insurance claim number, the name of the provider and physician, date of admission, and dates of services, if any, for which Medicare payment will not be made. H. Record of the Reconsideration Maintain the record (i.e., file) of your reconsideration until the later of 4 years after the date on the notice of your determination or completion of litigation and the passage of the time period for filing all appeals. The record (file) must include:  The initial denial determination and its basis (i.e., all documents associated with the determination);  A copy of the initial denial notice;  Documentation of the date of the receipt of the parties' request for reconsideration;  Evidence submitted by the parties in support of the reconsideration request;  The basis for the reconsidered determination;  A copy of the reconsideration notice; and  Documentation of when the initial denial and reconsideration notices were given/mailed out to the parties (This may be written in a separately kept log).