Required Elements in Appeals Correspondence

290.4 - Required Elements in Appeals Correspondence (Rev. 2926, Issued: 04-11-14, Effective: 07-14-14, Implementation: 07-14-14) The following should be used in all appeals correspondence: • The name of the beneficiary/provider/physician/supplier to whom the letter is addressed rather than “Dear Sir/Madam;" • Correspondence is identified by either the date on written correspondence or the date the written correspondence was received; • The name of the provider, physician or supplier as well as the date(s) of service; • When appropriate, an explanation in letters to beneficiaries, explaining why he/she is being sent a letter if the appeal came from the provider, physician or other supplier; • The appeal determination/decision is placed in the beginning of the letter; • Explicit rationale that describes why the items or services at issue do not meet Medicare guidelines. Merely stating that an item or service is “not medically reasonable and necessary under §1862(a)(1)” or “not medically reasonable and necessary under Medicare guidelines” does not provide any rationale. The rationale should include a description of the logic that led to the decision, references used to support the decision, and other information that is relevant to support the decision in the case; • When the appeals correspondence includes Medicare statutory citations, they must be related to the decision in layman’s terms. The statutory cite is listed as a parenthetical at the end of the sentence. For example, instead of beginning a sentence with, “§1879 of the Social Security Act states that...,” the sentence should start with “Under Medicare law, suppliers must...(§1879 of the Social Security Act)”; • Whenever the person is to receive some further response, such as an MSN (if available), an estimated time frame as to when he/she will receive it is provided; • Telephone number on all correspondence for additional questions; • What, if anything, must be done next, and by whom; • As appropriate, the results of any consultations with professional medical staff; • When applicable, a statement advising the appellant that upon written request the MAC will provide them copies of regulations, statutes, and guidelines used in making the determination; • For appeals, if the redetermination is partially or wholly favorable, an explanation about why the new determination is different from the previous determination; and • The correspondence must be written in a clear manner and with a customer- friendly tone.