Model Dismissal Notices

310.6.2 - Model Dismissal Notices (Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) NOTE: This is a model letter and may need to be adjusted to include additional verbiage/instructions if a MAC has received approval to receive appeal requests via a secure Internet portal/application. (Start) EXHIBIT 2: Model Redetermination Dismissal Notice For Incomplete or Invalid Request MONTH, DATE, YEAR APPELLANT NAME MEDICARE NUMBER OF ADDRESS BENEFICIARY: CITY, STATE ZIP CONTACT INFORMATION: If you have questions, write or call: MAC Name Address City, State Zip Telephone number RE: <Include claim identifier or appeal number> Dear <Appellant’s Name>: This letter is in response to your appeal request (also known as a redetermination) that was received in our office on <INSERT DATE>. The redetermination was requested for the following dates of service <INSERT DATE(S)>). Your redetermination request has been dismissed because it did not form a valid request for redetermination. In order to process a redetermination request, we need the following item(s) to be addressed: <INSERT ALL APPLICABLE INFORMATION>: Missing Information: • The beneficiary’s name; • The Medicare number of the beneficiary; • The specific service(s) and/or item(s) for which the redetermination is being requested and the specific date(s) of service; • The name of the person filing the redetermination request. Invalid Request: • The requestor is not a proper party; • Defective Appointment of Representation (AOR) <for non-beneficiary submitted claims only>; • No initial determination on the claim(s) appealed; or • Beneficiary is deceased with no remaining party or appointed representative with financial interest. Your request was determined to be invalid as explained above and therefore has been dismissed. You may file your request again if it has been 120 days or less since the date of receipt of the initial determination notice. When you file your request, please make sure you have addressed all of the above listed items and send your request to our office at the address noted above. If you disagree with this dismissal, you have two additional options: 1. You may request that we vacate our dismissal. We will vacate our dismissal if you demonstrate that you have good and sufficient cause for failing to submit a valid request. Your request to vacate this dismissal must be received at the address above within 6 months of the date of receipt this notice. 2. If you think we have incorrectly dismissed your request (that is, you believe you did address all of the above listed items in your request), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC). Your request must be received by the QIC at the address below within 60 days of receipt of this letter. In your request, please explain why you believe the dismissal was incorrect. The QIC will not consider any evidence for establishing coverage of the claim(s) being appealed. Their examination will be limited to whether or not the dismissal was appropriate. Please send your request to: <INSERT QIC ADDRESS> Sincerely. NAME, TITLE MAC NAME (End) EXHIBIT 2 (Start) EXHIBIT 3: MONTH, DATE, YEAR APPELLANT NAME MEDICARE NUMBER OF ADDRESS BENEFICIARY: CITY, STATE ZIP CONTACT INFORMATION: If you have questions, write or call: MAC Name Address City, State Zip Telephone number RE: <Include claim identifier or appeal number> Dear <Appellant’s Name>: This letter is in response to your appeal request (also known as a redetermination) that was received in our office on <INSERT DATE>. The redetermination was requested for dates of service <INSERT DATE(S)>. The initial determination for the items/services in dispute was issued on <INSERT DATE OF RA/MSN>. Your redetermination request has been dismissed because the date(s) of service in question is/are past the time limit to file a request for a redetermination. A redetermination request must be received in our office within 120 days of the date of receipt of the initial determination date on the Medicare Remittance Advice or the Medicare Summary Notice. The date of receipt of the initial determination is presumed to be 5 days after the date of the notice unless there is evidence to the contrary. Model Redetermination Dismissal Notice For An Untimely Appeal When we receive a request that has been filed late, we consider whether the appellant had good cause for filing late. In special circumstances, we may allow additional time to file. In this case, we did not find good cause for filing your request late. If you disagree with this dismissal, you have two options: 1. You may request that we vacate our dismissal. We will vacate our dismissal if you demonstrate good and sufficient cause for filing late. Your request to vacate this dismissal must be received at the address above within 6 months of the date of receipt of this notice. 2. If you think we have incorrectly dismissed your request (for example, you believe you did file your request on time), you may request a reconsideration of this dismissal by a Qualified Independent Contractor (QIC). Your request must be received by the QIC at the address below within 60 days of receipt of this letter. In your request, please explain why you believe the dismissal was incorrect. Please note that the QIC will not consider any evidence for establishing coverage of the claim(s) being appealed. Their examination will be limited to whether or not the dismissal was appropriate. Please send your request to: <INSERT QIC ADDRESS> Sincerely. NAME, TITLE MAC NAME (End) Exhibit 3