Filing a Request for a Reconsideration

320.1 - Filing a Request for a Reconsideration (Rev. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) The request for a reconsideration made by a beneficiary, provider, supplier, or State must be filed with the QIC specified in the redetermination notice. A request from a provider, supplier, or State must be made in writing either on the Form CMS-20033 (the reconsideration request form included with the redetermination), or must contain the following items: • The beneficiary’s name; • Medicare number; • The specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service; • The name of the party or representative of the party filing the request; and • The name of the contractor that made the redetermination. A request from a beneficiary must be made in writing either on a standard CMS form or another written format indicating dissatisfaction with the redetermination. Requests for reconsideration may be submitted in situations where beneficiaries assume that they will receive a reconsideration by questioning a payment detail of the determination or by sending additional information back with the MSN or MRN, but don’t actually say: I want a reconsideration. For example, a written inquiry stating, “Why did you only pay $10.00?” is considered a request for reconsideration. Common examples of phrasing in letters from beneficiaries that constitute requests for reconsideration: • “Please reconsider my claim.” • “I am not satisfied with the amount paid - please look at it again.” • “My neighbor got paid for the same kind of claim. My claim should be paid too.” The beneficiary’s request may contain the word appeal or review. There may be instances in which the word review is used but where the clear intent of the request is for a status report. This should be considered an inquiry. A. Request for Reconsideration (Form CMS-20033) The CMS provides a form for filing a request for reconsideration for the convenience of appellants, but appellants are not required to use this form. The form is available on the CMS.gov website at: http://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/Downloads/CMS20033.pdf. B. Requests Submitted to the Wrong Contractor Parties must request a reconsideration at the QIC with jurisdiction. Contractors with multiple States may have multiple QICs handling requests and, therefore, must make certain to refer the appellant to the correct QIC. The jurisdiction for all Part A QIC appeals is dependent upon the State where the service or item was rendered. The jurisdiction for all DME and Part B QIC appeals is dependent upon the State where the beneficiary resides. See §320.7 for the specific QIC jurisdictions. There may be instances where requests for QIC reconsiderations are misfiled with a contractor. Contractors shall have standard operating procedures to ensure that misfiled requests are identified and sent/transmitted to the proper location. If the contractor receives a ‘request for reconsideration’ from a party, or a ‘request for reconsideration’ mistakenly directed to them by another contractor, and the contractor has already conducted a redetermination, the contractor shall forward the request to the appropriate QIC, along with the case file(s), within 60 calendar days of receipt in the corporate mailroom. The case file must be sent either by an electronic means agreed upon in the JOAs or by a courier service so that the case file is received by the QIC before or on the 61st calendar day after the receipt. Contractors shall track all misfiled reconsideration requests to ensure receipt at the proper QIC. The QIC will send the MAC or DME MAC an acknowledgement of receipt of any misfiled requests. Contractors shall not count such misfiled requests as dismissals. The contractor counts the costs associated with misfiled requests in the CAFM line designated for preparing/transferring case files to the QIC. To aid in preventing misfiled requests for QIC reconsiderations, contractors shall employ provider education efforts with an emphasis on filing locations, as well as the dates for workload transitions when a MAC jurisdiction is transferred from one contractor to the next at the close of a contract’s period of performance. NOTE: If the contractor receives a ‘request for reconsideration’ (assuming the appellant is using the wrong form or terminology), but determines that a redetermination has not been conducted, the contractor does not forward the request to the QIC. The contractor shall conduct a redetermination.