CMS Decisions Subject to the Administrative Appeals Process

200 - CMS Decisions Subject to the Administrative Appeals Process (Rev. 12423; Issued: 12-20-23; Effective: 01-01-24; Implementation: 01-02-24) A. Entitlement Determinations In accordance with a memorandum of understanding with the Secretary, the Social Security Administration (SSA) makes initial Part A and Part B entitlement determinations and initial determinations on applications for entitlement. Individuals should contact the SSA for administrative appeals involving entitlement (telephone 1-800-772-1213 (TTY 1-800-325-0778 or access the SSA’s website at: http://ssa.gov/pgm/medicare.htm). This would include issues that involve the question of whether the beneficiary: • Has attained age 65 or is entitled to Medicare benefits under the disability or renal disease provisions of the law; • Is entitled to a monthly retirement, survivor, or disability benefit; • Is qualified as a railroad beneficiary; • Met the deemed insured provisions; and • Met the eligibility requirements for enrollment under the supplementary medical insurance (SMI) program or for hospital insurance (HI) obtained by premium payment. If a beneficiary is dissatisfied with the SSA’s initial determination on entitlement, he or she may request a reconsideration with the SSA. The SSA performs a reconsideration of its initial determination in accordance with 20 CFR part 404, subpart J. Following the reconsideration, the beneficiary may request a hearing before a HHS Administrative Law Judge (ALJ). If the beneficiary obtains a hearing before an ALJ and is dissatisfied with the decision of the ALJ, he or she may request the Appeals Council to review the case. Following the action of the Appeals Council, the beneficiary may be entitled to file suit in Federal district court. B. Initial Determinations The Medicare contractor makes initial determinations regarding claims for benefits under Medicare Part A and Part B. A finding that a request for payment does not meet the requirements for a Medicare claim shall not be considered an initial determination. An initial determination for purposes of this chapter includes, but is not limited to, determinations with respect to: (1) Whether the items and/or services furnished are covered under title XVIII of the Act; (2) In the case of determinations on the basis of section 1879(b) or (c) of the Act, whether the beneficiary, or supplier who accepts assignment under 42 CFR 424.55 knew, or could reasonably have been expected to know at the time the services were furnished, that the services were not covered; (3) In the case of determinations on the basis of section 1842(l)(1) of the Act, whether the beneficiary or supplier knew, or could reasonably have been expected to know at the time the services were furnished, that the services were not covered; (4) Whether the deductible has been met; (5) The computation of the coinsurance amount; (6) The number of days used for inpatient hospital, psychiatric hospital, or post-hospital extended care; (7) Periods of hospice care used; (8) Requirements for certification and plan of treatment for physician services, durable medical equipment, therapies, inpatient hospitalization, skilled nursing care, home health, hospice, partial hospitalization services, and intensive outpatient services; (9) The beginning and ending of a spell of illness, including a determination made under the presumptions established under 42 CFR 409.60(c)(2), and as specified in 42 CFR 409.60(c)(4); (10) The medical necessity of services, or the reasonableness or appropriateness of placement of an individual at an acute level of patient care made by the Quality Improvement Organization (QIO) on behalf of the contractor in accordance with 42 CFR 476.86(c)(1); (11) Any other issues having a present or potential effect on the amount of benefits to be paid under Part A or Part B of Medicare, including a determination as to whether there has been an underpayment of benefits paid under Part A or Part B, and if so, the amount thereof; (12) If a waiver of adjustment or recovery under sections 1870(b) and (c) of the Act is appropriate: (i) when an overpayment of hospital insurance benefits or supplementary medical insurance benefits (including a payment under section 1814(e) of the Act) has been made with respect to an individual, or (ii) with respect to a Medicare Secondary Payer recovery claim against a beneficiary or against a provider or supplier; (13) Whether a particular claim is not payable by Medicare based upon the application of the Medicare Secondary Payer provisions of section 1862(b) of the Act; (14) Under the Medicare Secondary Payer provisions of section 1862(b) of the Act that Medicare has a recovery claim against a provider, supplier, or beneficiary for services or items that have already been paid by the Medicare program, except when the Medicare Secondary Payer recovery claim against the provider or supplier is based upon failure to file a proper claim as defined in 42 CFR part 411 because this action is a reopening; (15) A claim not payable to a beneficiary for the services of a physician who has opted-out. NOTE: A physician who has opted-out of Medicare is not considered a party to the initial determination or any subsequent appeal; and (16) Under the Medicare Secondary Payer provisions of section 1862(b) of the Act that Medicare has a recovery claim if Medicare is pursuing recovery directly from an applicable plan. That is, there is an initial determination with respect to the amount and existence of the recovery claim. C. Actions That Are Not Initial Determinations Actions that are not initial determinations and are not appealable under this chapter include, but are not limited to— (1) Any determination for which CMS has sole responsibility, for example: whether an entity meets the conditions for participation in the program; whether an independent laboratory meets the conditions for coverage of services; or a determination under the Medicare Secondary Payer provisions of section 1862(b) of the Act of the debtor for a particular recovery claim; (2) The coinsurance amounts prescribed by regulation for outpatient services under the prospective payment system; (3) Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a contractor has sole responsibility under Part B, such as the establishment of a fee schedule set forth in 42 CFR, part 414, subpart B, or an inherent reasonableness adjustment pursuant to 42 CFR 405.502(g) and any issue regarding the cost report settlement process under Part A: NOTE: For example, section 1848(i)(1) of the Act prohibits administrative and judicial review of the individual components used to compute Medicare physician fee schedule payment amounts. However, a payment amount determination with respect to a particular item or service on a claim is an initial determination that is appealable. (4) Whether an individual's appeal meets the qualifications for expedited access to judicial review provided in 42 CFR 405.990; (5) Any determination regarding whether a Medicare overpayment claim should be compromised, or collection action terminated or suspended under the Federal Claims Collection Act of 1966, as amended; (6) Determinations regarding the transfer or discharge of residents of skilled nursing facilities in accordance with 42 CFR 483.5 (definition of transfer and discharge) and 483.15; (7) Determinations regarding the readmission screening and annual resident review processes required by 42 CFR part 483, subparts C and E; (8) Determinations with respect to a waiver of Medicare Secondary Payer recovery under section 1862(b) of the Act; (9) Determinations with respect to a waiver of interest; (10) Determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions (as opposed to the application in a particular case); (11) Determinations under the Medicare Secondary Payer provisions of section 1862(b) of the Act that Medicare has a recovery against an entity that was or is required or responsible (directly, as an insurer or self-insurer; as a third party administrator; as an employer that sponsors, contributes to or facilitates a group health plan or a large group health plan; or otherwise) to make payment for services or items that were already reimbursed by the Medicare program, except with respect to the amount and existence of a recovery claim under section 1862(b) of the Act where Medicare is pursuing recovery directly from an applicable plan as specified in 42 CFR 405.924(b)(16); (12) A contractor's, QIC's, ALJ's, OMHA attorney adjudicator’s, or Appeals Council’s determination or decision to reopen or not to reopen an initial determination, redetermination, reconsideration, hearing decision, or review decision; (13) Determinations that CMS or its contractors may participate in the proceedings on a request for an ALJ hearing or act as parties in an ALJ hearing or Appeals Council review; (14) Determinations that a provider or supplier failed to submit a claim timely or failed to submit a timely claim despite being requested to do so by the beneficiary or the beneficiary’s subrogee; (15) Determinations with respect to whether an entity qualifies for an exception to the electronic claims submission requirement under 42 CFR part 424; (16) Determinations by the Secretary of sustained or high levels of payment errors in accordance with section 1893(f)(3)(B); (17) A contractor's prior determination related to coverage of physicians' services; (18) Requests for anticipated payment under the home health prospective payment system under 42 CFR 409.43(c)(ii)(s); and (19) Claim submissions on forms/formats that are incomplete, invalid, or do not meet the requirements of a Medicare claim and returned or rejected to the provider or supplier. NOTE: Duplicate items and services are not afforded appeal rights, unless the supplier is appealing whether or not the service was, in fact, a duplicate. D. Initial Determinations Subject to Reopening Minor errors or omissions in an initial determination may be corrected only through the contractor’s reopening process. Since it is neither cost efficient or necessary for contractors to correct clerical errors through the appeals process, requests for adjustments to claims resulting from clerical errors must be handled and processed as reopenings. In situations where a provider, supplier, or beneficiary requests an appeal and the issue involves a minor error or omission, irrespective of the request for an appeal, contractors shall treat the request as a request for reopening. A contractor must transfer the appeal request to the reopenings unit or other designated unit for processing. See Chapter 34 Section 10.1 Authority to Conduct a Reopening of the Medicare Claims Processing Manual for information specific to conducting a reopening when a redetermination was requested.