Good Cause - Administrative Relief Following a Disaster

240.4 – Good Cause - Administrative Relief Following a Disaster (Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) When a disaster occurs, whether natural or man-made, MACs shall anticipate both an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks. For appeals purposes, as defined in this IOM, a ‘disaster area’ is declared by the Federal Emergency Management Agency (FEMA). In disaster situations, MACs that process appeals for beneficiaries, providers, and suppliers affected by a disaster shall exercise good cause in accordance with the regulations and follow the guidance below regarding how to process Fee-for-Service appeal requests in an area(s) declared by FEMA as a disaster area. When a Presidential declaration occurs, the HHS Secretary may, under section 319 of the Public Health Service Act, declare that a Public Health Emergency (PHE) exists in the affected State. Once a PHE is declared, section 1135 of the Social Security Act authorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements as determined necessary by CMS. A. Definition of Disaster A disaster is defined as any natural or man-made catastrophe (such as hurricane, tornado, earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, fire, flood, or explosion) which causes damage of sufficient severity and magnitude to partially or completely destroy medical records and associated documentation that could be needed and/or requested by the MACs in the course of the adjudication process, interrupts normal mail service (including US Postal delivery, overnight parcel delivery services, etc.), impacts ability to file appeals in a timely manner, and/or otherwise significantly limit the provider’s/supplier's daily operations. A disaster may be widespread and impact multiple structures (e.g., a regional flood) or isolated and impact a single site only (e.g., water main failure). The fact that a provider/supplier is located in a presidentially declared disaster area under the power of the Stafford Act is not sufficient in itself to justify administrative relief, as not all structures in the disaster area may have been subject to the same amount of damage. Damage must be of sufficient severity and extent to compromise retrieval of medical records. The provider/supplier needs to state that they were impacted by the disaster. B. Basis for Providing Administrative Relief In the event of a disaster, MACs shall grant temporary administrative relief to any affected providers and suppliers for up to 6 months (or longer with good cause). Administrative relief is to be granted to providers/suppliers/beneficiaries on a case-by-case basis in accordance with the following guidelines: 1. Situation: A provider/supplier/beneficiary in the affected area needs an extension to file a request for an appeal. Action: The MAC shall grant an extension to request an appeal under the good cause exception. Please see 42 CFR § 405.942. If the request is related to an overpayment, the MAC shall accept the request and stop recoupment immediately. 2. Situation: The MAC has requested or needs to request additional documentation for a pending appeal, but the provider/supplier/beneficiary has been impacted by a disaster. Action: The MAC shall hold the request until the documentation can be obtained or submitted. However, to the extent that the contractor can use other data sources that are available to substantiate payment for the claim, it should do so. The CMS will waive the timeliness requirements for processing these appeals. 3. Situation: A request for an appeal filed by an appointed representative on behalf of a party contains a missing or defective appointment instrument and the party is in the affected area. Action: The contractor shall process the request and attempt to obtain the corrected appointment instrument. If the corrected appointment instrument is not received by the end of the appeals adjudication period, contractors shall send the redetermination decision letter to the appellant party and any other party to the appeal, but not to the individual attempting to act as the representative. 4. Situation: A MAC receives a request for redetermination from a provider/supplier/beneficiary in the affected area and the request is missing some of the required elements to make it a valid request. However, the MAC has information in the shared systems that would allow it to identify the missing element(s). Action: The MAC shall accept and process the request, using information already available to it via the shared system. C. Verification In the case of complete destruction of medical records where no backup records exist, MAC Appeal Units and QICs shall accept an attestation that no medical records exist and consider the services covered and correctly coded.