Assembling the Hearing Claim File - (Rev. 4, 07-18-03)

7520 - Assembling the Hearing Claim File - (Rev. 4, 07-18-03) Complete documentation is vital. It is the foundation upon which to make and sustain determinations. Inadequate documentation leads to improper and inconsistent determinations, delays in the appeals process, and reversals at higher appellate levels. Therefore, when assembling the case file, make sure you include all pertinent material. Files furnished for ALJ hearings must provide specific rationale supporting your determination (Cite applicable sections of the statute and regulations and/or published precedents). The statute, regulations, CMS rulings, and national coverage determinations are binding on ALJs. It is important to cite appropriate regulations because these coincide with the ALJ frame of reference. CMS manual instructions are not binding on ALJs unless the statute or regulations specifically incorporates them. National coverage determinations are found in the Coverage Issues Manual. The CMS Rulings contain precedent case dispositions, statements of policy, and interpretations of the law and regulations, which you are to follow. CMS Rulings are binding on all CMS components, the Provider Reimbursement Review Board, and ALJs who hear Medicare appeals. These decisions promote consistency in interpretation of policy and adjudication of disputes. A. Listing of Documentation Required for Hearing Obtain the following documentation before you forward the file to OHA. If any of the evidence deemed necessary is not in existence, or is otherwise unobtainable, fully document this and explain.  Medical Records -- The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medication and services (See 42 CFR 482.24(c)). If possible, send a copy of the entire medical record. Generally, the medical record contains the following documents: • Consent to treatment statement; • Consultations, if any; • Demographics sheet (e.g., face sheet); • Discharge summary; • Discharge/transfer instructions; • Emergency department records, if any; • Graphic sheets; • History and physical; • Intake/output sheets; • IV flow sheets, if any; • Laboratory results (e.g., blood work, urine tests); • Medication records; • Nursing assessments; • Operative/procedural consent to treatment statement, if any; • Operative reports, if any; • Physician attestation statement; • Physician's orders; • Problem list, if any; • Progress notes (e.g., physician, nurse, other multi-disciplined practitioners); • Rehabilitation reports, if any; and • Test results (e.g., X-rays, MRIs, EKGs, CAT scans), if any.  QIO Documents -- Include the following documents from your files: • Notice of initial denial determination, including a determination on limitation on liability (See §7115 for denial notice content); • Request for reconsideration (See §7430.G.1 for reconsideration notice content); • Request for hearing; and • Reconsideration determination notice including a determination on limitation on liability. To support your reconsideration determination, include the following information:  The professional qualifications and experience of the physician reconsideration reviewer. Explain that in accordance with regulations governing disclosure of confidential QIO information you may not reveal the identity of the reviewer unless he/she gives his/her consent (See 42 CFR 480 and §7430); and  Rationale supporting the determination with the corresponding statute/regulation. Provide your rationale in your reconsideration letter so that it may be taken into consideration by OHA. It is not sufficient to add an explanation to the hearing file. To request a hearing, the beneficiary or his/her representative (whose appointment has been properly documented) may send a letter or submit OHA's Form CMS-5011-U6, Request for Hearing (See Exhibit 7-62). If a beneficiary submits a letter requesting a hearing without Form CMS-5011-U6, fill out Form CMS-5011-U6 and attach the incoming letter and the form to a letter to OHA that includes the following statement: "See attached letter dated." Staple the letter and the postmarked envelope in which it arrived to the hearing request form. You are not responsible for completing Form SSA- 1696-U4, Appointment of Representative. Instead, check the appropriate blank under Item 19A on Form CMS-384, QIO Case Summary, indicating whether a completed beneficiary representative form is on file. NOTE: Upon receipt of a request for hearing, it is imperative that you date-stamp the request. A request is considered filed on the date it is postmarked (See 42 CFR 8.42(b)(3)). Also, retain a copy of the envelope in which the request for hearing was received in order to have a record of the exact date a request was filed.  Other Pertinent Documents -- Include the following pertinent documents in your file: • Hospital denial notice, preadmission/pre-procedure denial notice and the physician's response to the pre-denial notice. These documents may be the only records in the file if the beneficiary was never subsequently admitted to the hospital or the procedure was never performed following a preadmission/pre-procedure denial; • Copies of prior denial notices that involve the same or reasonably comparable conditions. These are especially important for appeals made under the limitation on liability provision; • Copies of the laws and regulations not otherwise referenced in your determination on which you relied; • Copies of relevant review criteria with a statement explaining that you developed the review criteria with the assistance of specialty physicians from your State and that they are medically recognized indicators of care that reflect local standards of medical practice. Also, include a copy of CMS' generic quality screens that have been applied to the case, if appropriate; • Copies of the actual document/bulletin/MOU containing the information given to the provider community. Reference actual documents sent to the hospitals, which may include relevant pages of the QIO Manual; and • All appropriate billing forms and current benefit data from the claim history. If billing forms and benefit data are not available in the file, request that the Fiscal Intermediary (FI) send this information to the appropriate hearing office (See Exhibits 7-63 and 7-64). Do not hold the hearing folder if you only need FI data. Forward the folder directly to OHA. NOTE: These documents support your determination. ALJs rule based on preponderance of evidence. The parties to the appeal can bring medical specialists and lawyers to the hearing to establish evidence on their behalf (Party is legally defined as "a person or group involved in a legal proceeding"). However, because neither CMS nor the QIO is a party, ensure that the file forwarded to OHA is as complete as possible. B. Assembling the Hearing Claim File Place all hearing requests in folders before you send them to the hearing office. Each folder must contain the beneficiary's Health Insurance Claim Number (HICN) (i.e., Medicare number) on one line followed directly underneath by the surname, first name, and middle initial (if known). All claims material that pertains to services in question, including the envelope in which the request for hearing was received, must be profiled in this folder in chronological order by type of evidence (e.g., nurse's notes, physician's orders) with the most current material on top. To provide the ALJ with a concise overview of your determination, add a sheet with qualifications and experience of the physician reconsideration reviewer and his/her rationale supporting the determination with the corresponding statute/regulation. Include documents to support your limitation on liability determination.