Medicare Redetermination Notice (For Partly or Fully Unfavorable

310.7 - Medicare Redetermination Notice (For Partly or Fully Unfavorable Redeterminations) (Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) The contractor uses the following Medicare Redetermination Notice (MRN) format or something similar and standard language paragraphs whether the redetermination notice is delivered via hard copy mail or via a CMS-approved portal/application. NOTE: This is a model letter and should be adjusted on a case by case basis if necessary. Contractors may also include additional resources, including their website address(es) and/or telephone number(s). Appeals that involve issues such as Medicare Secondary Payer (MSP) and overpayment recoveries may require contractors to deviate from the sample given in this manual section. Contractors must also include reference within all appropriate sections of the appeal decision letter that in instances where services are covered (for example, a partially favorable decision is rendered), the beneficiary may also be responsible for any copayments, coinsurance, or deductibles related to the covered portion of the service or item that is payable. The contractor must ensure that the information identified in each section of the model letter below is included and addressed, as needed, in the MRN. Contractors shall include the request for reconsideration form with the MRN. The contractor must fill in the contract number and “appeal number” on each request for reconsideration form. The contract number is only required for contractors who have multiple locations in which a QIC will need to request a case file. The “appeal number” is any number used to identify the associated appeal and will be used by the QIC to request a case file. The contractor also shall include the contractor logo or CMS logo with the contractor name and address on the reconsideration request form for identification purposes. This logo will be used by the QIC to identify which contractor to request the case file from. A. Redetermination Letter The redetermination letterhead must follow the instructions issued by CMS for contractor written correspondence requirements (see §290), unless otherwise instructed and/or agreed to by CMS. (Start) EXHIBIT 4: MONTH, DATE, YEAR APPELLANT NAME MEDICARE NUMBER OF ADDRESS BENEFICIARY: CITY, STATE ZIP CONTACT INFORMATION: If you have questions, write or call: Contractor Name Address City, State Zip Telephone number RE: <Include claim identifier or appeal number> MEDICARE APPEAL DECISION <If the appellant is a provider or supplier, in the beneficiary’s letter, contractors must include language to indicate the beneficiary is receiving a copy of the decision. For example, “This is a copy of the letter sent to <your provider> <your physician> <your supplier> <the party who requested this appeal>” or, “Please note that if you did not request this appeal, you are receiving this letter as a copy.”> Dear <Appellant's Name>: Model Redetermination Notice This letter is to inform you of the decision on your Medicare appeal. An appeal is a new and independent review of a claim. You are receiving this letter because you requested an appeal for <insert: description of item or service>. The appeal decision is <Insert either: unfavorable. Medicare does not cover the item/service at issue in your appeal OR partially favorable. Medicare covers part of the claim(s) at issue in your appeal.> <Note: If the issue in the appeal is strictly a payment dispute, the language should read, for unfavorable decisions: “Medicare cannot make payment for the item/service at issue in your appeal” and for partially favorable decisions: “Medicare can make partial payment for the item/service at issue in your appeal.”> More information on the decision is provided below. If you disagree with the decision, you may appeal to a Qualified Independent Contractor (QIC). Your appeal of this decision must be made in writing and received by the QIC within 180 days of receipt of this letter. You are presumed to have received this decision five days from the date of the letter unless there is evidence to show otherwise. However, if you do not wish to appeal this decision, you are not required to take any action. For more information on how to appeal this decision, see the section at the end of this letter entitled, “Important Information about Your Appeal Rights.” A copy of this letter was also sent to <Insert: Beneficiary Name or Provider Name>. <Insert: Contractor Name> was contracted by Medicare to review your appeal. SUMMARY OF THE FACTS <Instructions: Contractors may present this information in this format, or in paragraph form.> Provider Dates of Service Type of Service <Insert: Provider Name> <Insert: Dates of Service> <Insert: Type of Service> • A claim was submitted for <insert: kind of services and specific number>. • An initial determination on this claim was made on <insert: date>. • The <insert: service(s)/item(s)> were/was denied because <insert: reason>. • On <insert: date> we received a request for a redetermination. • <Insert: list of documents> was submitted with the request. DECISION <Instructions: Insert a brief statement of the decision, for example "We have determined that (the specific items/services) are not covered by Medicare. We have also determined that (the provider) (the supplier) (the beneficiary) is responsible for the cost of the item(s)/service(s)."> EXPLANATION OF THE DECISION <Instructions: This is the most important element of the redetermination. Explain the logic/reasons that led to your final determination. Explain the coverage policy (LCD, NCD), regulations, policy guidance (IOM provisions), and/or laws used to make this determination. Make sure the rationale for the decision is clear and that it includes an explanation of why the claim can or cannot be paid for the particular set of facts at issue in the appeal. For example, the explanation should demonstrate how the beneficiary’s condition or circumstances do not meet specific coverage policy requirements. Statements such as "not medically reasonable and necessary under Medicare guidelines" or "Medicare does not pay for X" provide conclusions instead of explanation, and are not sufficient to meet the requirement of this paragraph.> WHO IS RESPONSIBLE FOR THE BILL? <Instructions: 1. Include, as applicable, information on limitation on liability under §1879 of the Act, physician refund requirements for non-assigned claims under §1842(l) of the Act, DMEPOS supplier refund requirements under §§1834 and 1879(h) of the Act, financial responsibility for benefit category denials (statutory exclusions), and waiver of overpayment recovery under §1870 of the Act. For example, if the denial reason triggers a liability determination under §1879 of the Act, include the following model paragraphs: “After determining that the item or service will not be covered by Medicare, we must determine who is financially liable for the denied item or service. When an item or service is denied under §1862(a)(1), §1862(a)(9), or §1879(g) of the Social Security Act (the Act), we must determine if the beneficiary and the provider or supplier either knew or could reasonably be expected to know that the item or service would not be covered. This is known as the limitation on liability provision of §1879 of the Act. If the beneficiary was informed by their provider or supplier in writing in advance of receiving the item/service that Medicare may not make payment (through receipt of an Advance Beneficiary Notice of Noncoverage (ABN)), the beneficiary may be responsible for the cost of the denied item or service. If the provider or supplier knew or could reasonably be expected to know the item or service would not be covered, but the beneficiary did not have such knowledge, then the provider or supplier may be responsible for the cost of the denied item or service.” 2. Include, as applicable, a statement regarding beneficiary knowledge of non-coverage and a statement regarding provider/supplier knowledge of non-coverage when liability under §1879 of the Act is at issue. If the provisions of §1879 of the Act do not apply to the coverage denial, then do not include a discussion of §1879 in the redetermination letter. For additional information regarding the application of §1879, see IOM 100-04, Ch. 30, §§10-30. Beneficiary model paragraphs for §1879 analysis – (Beneficiary Option 1) “We have determined that the beneficiary either knew or could reasonably be expected to know that the service/item would not be covered because [insert reason for determining that the beneficiary knew or could have been expected to know the item/service would not be covered; typically this is established when the provider/supplier delivers a validly executed ABN].” (Beneficiary Option 2) “There is no evidence to indicate that the (provider) (supplier) notified the beneficiary in advance that the item/service would not be covered by Medicare. Therefore, we have determined that the beneficiary did not know and could not reasonably have been expected to know that the item/service would not be covered.” Provider/Supplier model paragraphs for §1879 analysis – (Provider/supplier Option 1) “In addition, we have determined that the (provider) (supplier) either knew or could reasonably be expected to know that the service/item would not be covered. [Explain the basis for determining that the provider/supplier knew or should have known the item/service would not be covered] (Provider/supplier Option 2) “We have determined that the (provider) (supplier) did not know and could not reasonably have been expected to know that the item/service would not be covered. 3. Include a summary paragraph to explain the liability of the parties to the appeal. Model summary paragraph for appeals where liability under §1879 is at issue – “Since the (beneficiary) (provider) (supplier) has been determined to have had knowledge of the non-covered item/service, the (beneficiary) (provider) (supplier) is liable for the cost of the denied item/service. (The (provider or supplier) (may)(may not) bill the beneficiary for the cost of the denied item/service, and must refund any monies collected from the beneficiary.)” 4. As noted above, the contractor shall (1) explain the basis for their determination of knowledge when making a determination of liability under §1879 of the Act, and (2) state who is responsible for the bill. For example, a regulation, a CMS or contractor publication, or specific policy posted on the contractor’s website, etc. may establish knowledge of non-coverage. See IOM 100-04, Chapter 30, §40, et seq. for additional information. If the provider or supplier is held liable under §1879 of the Act for the cost of the item/service, they may not collect from or bill the beneficiary for the cost of the item/service. The provider or supplier must refund any money collected for the item/service, including any coinsurance or deductible. 5. If neither the beneficiary, nor the provider or supplier knew or could reasonably have been expected to know that the item/service would not be covered, then Medicare makes payment for the item/service under §1879 of the Act. 6. If there is evidence to indicate that the beneficiary may have paid in advance for the items/services (e.g., the claim was billed with a GA modifier indicating an ABN was given to the beneficiary), or paid the applicable deductible or coinsurance amounts, and the provider/supplier is subsequently held liable under §1879 of the Act for the denied items/services, the contractor shall include a statement explaining the provider/supplier’s obligation to refund any payments made by the beneficiary, including payment of any deductible or coinsurance. See §310.5.B. See also, 42 CFR 411.402; IOM 100-04, Chapter 30, §30.1.2, §30.2.2, and §100, et seq. for information regarding indemnification procedures and IOM 100-04, Chapter, 30, §§10-40 and 110-150 for more information on liability protections and refund requirements. 7. If the basis for denial does not trigger the limitation on liability provisions of §1879 of the Act, the contractor explains the reason for the denial and includes the following, or similar language: Since the item/service is (not a covered benefit under Medicare) (excluded from coverage under Medicare), we cannot make payment. The (provider) (supplier) may bill the beneficiary for the denied item/service. 8. Example of a complete financial responsibility section when a supplier is determined to be liable under §1879: After determining that the item or service will not be covered by Medicare, we must determine who is financially liable for the denied item or service. When an item or service is denied under §1862(a)(1), §1862(a)(9), or §1879(g) of the Social Security Act (the Act), we must determine if the beneficiary and the provider or supplier either knew or could reasonably be expected to know that the item or service would not be covered. This is known as the limitation on liability provision of §1879 of the Act. If the beneficiary was informed by their provider or supplier in writing in advance of receiving the item/service that Medicare may not make payment (through receipt of an Advance Beneficiary Notice of Noncoverage), the beneficiary may be responsible for the cost of the denied item or service. If the provider or supplier knew or could reasonably be expected to know the item or service would not be covered, but the beneficiary did not have such knowledge, then the provider or supplier may be responsible for the cost of the denied item or service. There is no evidence to indicate that the supplier notified the beneficiary in advance that the item/service would not be covered by Medicare. Therefore, we have determined that the beneficiary did not know and could not reasonably have been expected to know that the item/service would not be covered. In addition, we have determined that the supplier either knew or could reasonably be expected to know that the service/item would not be covered by Medicare. Based on the coverage limitations explained in the contractor’s Local Coverage Determination (LCD), L11518 (Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea), the supplier knew or should have known the item provided would not be covered. Since the supplier has been determined to have had knowledge of the non-covered item/service, the supplier is liable for the cost of the denied item/service. The supplier may not bill the beneficiary for the cost of the denied item/service, and must refund any monies collected from the beneficiary.> WHAT TO INCLUDE IN YOUR REQUEST FOR A RECONSIDERATION OF THIS APPEAL <Instructions: If the denial was based on insufficient documentation or if specific types of documentation are necessary to issue a favorable decision indicate what documentation would be necessary to pay the claim. Use option 1 if evidence is indicated in this section or option 2 if no further evidence is needed.> Option 1: <SPECIAL NOTE TO Medicare physicians, providers, and suppliers ONLY> Any additional evidence as indicated in this section should be submitted with the request for reconsideration. All evidence must be presented before the reconsideration decision is issued. If all additional evidence as indicated above and/or otherwise is not submitted prior to issuance of the reconsideration decision, you will not be able to submit any new evidence to the administrative law judge or the Medicare Appeals Council unless you can demonstrate good cause for withholding the evidence from the qualified independent contractor. NOTE: You do not need to resubmit documentation that was submitted as part of the redetermination. This information will be forwarded to the QIC as part of the case file utilized in the reconsideration process. Option 2: <SPECIAL NOTE TO Medicare physicians, providers, and suppliers ONLY> Any additional evidence as indicated in this section should be submitted with the request for reconsideration. All evidence must be presented before the reconsideration decision is issued. If all evidence is not submitted prior to the issuance of the reconsideration decision, you will not be able to submit any new evidence to the administrative law judge or the Medicare Appeals Council unless you can demonstrate good cause for withholding the evidence from the qualified independent contractor. NOTE: You do not need to resubmit documentation that was submitted as part of the redetermination. This information will be forwarded to the QIC as part of the case file utilized in the reconsideration process. Sincerely, NAME, TITLE CONTRACTOR NAME IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS Your Right to Appeal this Decision: If you do not agree with this decision, you may file an appeal. An appeal is a review performed by people independent of those who have reviewed your claim so far. The next level of appeal is called reconsideration. A reconsideration is a new and impartial review performed by a qualified independent contractor (QIC), separate and independent of (insert: contractor name). How to Appeal: To exercise your right to an appeal, you must file a request in writing. Your request must be received by the QIC at the address below within 180 days of receiving this decision. You are presumed to have received this decision five days after the date of the letter unless there is evidence to show otherwise. If you are unable to file your appeal request timely, please explain why you could not meet the filing deadline. You may request an appeal by using the form enclosed with this letter. If you do not use this form, you can write a letter. You must include: your name, the name of the beneficiary, the Medicare number, a list of the service(s) or item(s) that you are appealing and the date(s) of service, and any evidence you wish to attach. You must also indicate that (insert: contractor name) made the redetermination. You may also attach supporting materials, such as those listed in item 10 of the enclosed Reconsideration Request Form, or other information that explains why this service should be paid. Your doctor may be able to provide supporting materials. If you want to file an appeal, send your request to: <QIC Name Address City, State Zip> Who May File an Appeal: You or someone you name to act for you (your appointed representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. If you want someone to act for you, you may visit http://www.cms.gov/Medicare/CMS- Forms/CMS-Forms/downloads/cms1696.pdf to download the “Appointment of Representative” form, which may be used to appoint a representative. Medicare does not require that you use this form to appoint a representative. Alternately, you may submit a written statement containing the same information indicated on the form. If you are a Medicare beneficiary, you may also call 1-800-MEDICARE (1-800-633-4227) to learn more about how to name a representative. Other Important Information: If you want copies of statutes, regulations, policies, and/or manual instructions CMS used to arrive at this decision, or if you have any questions specifically related to your appeal, please write to us at the following address <alternatively, if using the same address at top of page one of letter, refer to that address rather than repeat the address here> and attach a copy of this letter: Contractor Name, A Medicare Contractor Address City, State Zip Resources for Medicare Beneficiaries: If you want help with an appeal, or if you have questions about Medicare, you can have a friend or someone else help you with your appeal. You can also contact your State health insurance assistance program (SHIP). You can find the phone number for your SHIP in your “Medicare & You” handbook, under the “Helpful Contacts” section of www.medicare.gov website, or by calling 1-800- MEDICARE (1-800-633-4227). Your SHIP can answer questions about payment denials and appeals. For general questions about Medicare, you can call 1-800-MEDICARE (1-800-633- 4227), TTY/TDD: 1-877-486-2048. Remember that specific questions about your appeal should be directed to the contractor that is processing your appeal. Reconsideration Request Form Directions: If you wish to appeal this decision, please fill out the required information below and mail this form to the address shown below. At a minimum, you must complete/include information for items 1, 2a, 6, 7, 11, & 12, but to help us serve you better, please include a copy of the redetermination notice with your request. 1. Name of Beneficiary: 2a. Medicare Number: 2b. Claim Number (ICN / DCN, if available): 3. Provider Name: 4. Person Appealing: ☐Beneficiary ☐Provider of Service ☐Representative 5. Address of the Person Appealing: 5a. Telephone Number of the Person Appealing: ____________________________ 5b. Email Address of the Person Appealing: ________________________________ 6. Item or service you wish to appeal: 7. Date of the service: From To 8. Does this appeal involve an overpayment? ☐Yes ☐No *Please include a copy of the demand letter (if applicable) with your request. 9. Why do you disagree? Or what are your reasons for your appeal? (Attach additional pages, if necessary.) 10. You may also include any supporting material to assist your appeal. Examples of supporting materials include: ☐ Medical Records ☐ Office Records/Progress Notes ☐ Copy of the Claim ☐Treatment Plan ☐ Certificate of Medical Necessity 11. Name of Person Appealing: 12. Date: Contractor Number (Contractor number is optional for contractors with only one location for QICs to request case files) (End) EXHIBIT 4 Contractor Logo or CMS Logo with Contractor Name and Address Redetermination/ Appeals Number: XXXXXX QIC Name Address