Appeal Decision Involving Multiple Beneficiaries

300.5 - Appeal Decision Involving Multiple Beneficiaries (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) A. Appeals of Overpayments Involving Multiple Beneficiaries with a Single Account Receivable If an appellant submits a request for redetermination that involves an overpayment with a single account receivable for claims involving multiple beneficiaries, the MAC shall issue one decision letter to the appellant that includes information specific to the claims for each beneficiary. The summary of facts, coverage, payment and liability decisions for each beneficiary’s claim(s) may be included as a separate attachment to the decision letter. Since each beneficiary is a party to the appeal, subject to the exception in §300.5.C below, the MAC shall send each beneficiary a copy of their own determination without compromising the privacy of other beneficiaries in the appeal. (Refer to IOM, 100-06, Medicare Financial Management Manual, Chapter 6, section 460.1, for instructions on how to count requests that involve multiple beneficiaries). B. Appeals Involving Claims of Multiple Beneficiaries, Other than Overpayments with a Single Account Receivable If a party files a request for redetermination that involves claims of multiple beneficiaries that do not comprise an overpayment with a single account receivable, the MAC may process the appeal by issuing a separate decision letter for each beneficiary's claim(s) (i.e., as a split appeal), or the MAC may issue a single letter with attachments for each separate claim, whichever is more efficient. Example: If a supplier submits a single appeal request involving unrelated claims for various beneficiaries that were denied on prepayment review or through prepayment edits, the MAC may process the appeal as a split and issue separate letters to the supplier-appellant, or the MAC may issue a single letter with attachments for each claim. In either case, the beneficiary, as a party to the appeal, must receive a copy of the decision letter that pertains to his or her claims. Example: If a supplier submits a single appeal request involving claims reviewed by a recovery auditor on a postpayment basis, resulting in overpayments (not extrapolated) processed as separate accounts receivable, the MAC may issue either a single decision letter to the appellant with attachments for each claim, or separate decision letters, whichever is more efficient. The beneficiary, as a party to the appeal, must receive a copy of the decision letter that pertains to his or her claims, subject to the exception noted in §300.5.C below. C. Exception to Sending Decision Letters to Beneficiaries in Overpayment Cases In an overpayment case involving multiple beneficiaries who have no financial liability prior to, and following the redetermination, the MAC mails the decision letter to the appellant or their appointed representative. In this situation, MACs are not required to send the decision letters to beneficiaries who are parties to the redetermination (see 42 CFR 405.956(a)(2)). However, if financial liability shifts from the provider or supplier to the beneficiary, the MAC issues a separate decision letter to the beneficiary that explains why he/she is liable, and explains the subsequent appeal rights available. Example: During a postpayment review, claims for multiple beneficiaries are initially denied as being not medically reasonable and necessary, and the determination of liability under section 1879 of the Act finds the physician financially responsible for the denied services. If during the appeal, the physician demonstrates that a valid ABN was issued for some of the services provided to certain beneficiaries and financial responsibility shifts from the physician to those beneficiaries, the MAC must issue separate decision letters to the affected beneficiaries, but is not required to issue separate decision letters to those beneficiaries whose liability has not changed (i.e., liability remains with the physician).