Intermediary Appeal Requests

100.2 – Section A – Intermediary Appeal Requests (Rev. 45, 05-28-04) This part concerns data from Part A and Part B appeals processes. The number of appeals requested (received), completed, and pending reflects the status of the workload as of the last day of the reporting month. Base data on actual counts of each activity and not on sampling or other estimating techniques. Appeals fall into the following categories: 1. Part A Reconsideration.--This is the first level of appeal following denial of a Part A claim. It is a re-evaluation of the facts and findings of a claim to determine whether the initial decision was correct. (See §3781.) Do not count duplicate reconsideration requests or reconsideration requests received before you have made an initial determination on a claim. Do not count telephone requests for reconsiderations or inquiries. Count one reconsideration per request received. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests. 2. Part B Review.--This is the first formal level of appeal following denial of a Part B claim. It is a second look by a different employee at the claim and supporting evidence. (See §§3792 ff.) 3. Part B Hearing.--This is an independent determination resulting from an appeal of your review decision. This independent determination is rendered by a Hearing Officer (HO) you assigned. The amount in controversy must be at least $100. (See §§3794ff.) Definition of Columns: Column (1) TOTAL--All Part A reconsiderations. Column 1 must equal the sum of columns 2, 3 and 4. Column (2) SNF.--All skilled nursing facility reconsiderations. Column (3) HHA/HOSPICE.--All home health agency and hospice reconsiderations. Column (4) OTHER.--All other Part A reconsiderations. Column (5) PART B REVIEWS.--Count one review per request received (i.e., Form CMS-1964 or equivalent written request). Do not count duplicate review requests or review requests received before you have made an initial determination on a claim. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests. (Report claim counts in line 7.) Column (6) PART B HEARINGS.--Count one hearing per request received (i.e., Form CMS- 1965 or equivalent written request). Include hearings requested that do not meet the minimum $100 requirements and are subsequently dismissed. With the exception of line 7 of the CMS-2591, do not count the number of claims or beneficiaries involved in the requests. (Report claim counts in line 7.) Do not count hearing requests that qualify for a Part B ALJ hearing. (Part B intermediary hearings are those Part B hearings that a hearing officer adjudicates, as opposed to an ALJ). See definition for Section C. Do not count requests for HO hearings received after you rendered an on-the-record (OTR) decision in lines 1-44 of the report. Count these cases only in lines 45, 46, 47, 48 and 50 as appropriate. Line 1. Opening Pending.--Show under columns 1-4, the number of reconsiderations reported on line 19 as the closing pending on the previous month's report. Show under column 5 the number of reviews reported on line 30 as the closing pending on the previous month's report. Show under column 6 the number of hearings reported on line 40 as the closing pending on the previous month's report. Line 2. Adjustments to Pending.--If it is necessary to revise the pending figure for the close of the previous month because of inventories or reporting errors, enter the adjustment. Report requests received near the end of the reporting month and placed under control in the subsequent month as received in the reporting month, not as requests received in the subsequent month. If some cases were not counted in the proper month's receipts, count them as adjustments to the opening pending in the subsequent month. If line 3 of the current month differs from the closing pending of the previous month, there must be an entry in line 2 for the current month. Precede the entry by a "+" or "-", as appropriate. Line 3. Adjusted Pending.--Enter the result of line 1 + line 2 (taking into account the "-" sign, if any). Line 4. Requests Received.--Show, under the appropriate columns, the number of requests for reconsiderations, reviews, and Part B intermediary hearings received during the reporting month. Include requests transferred to you by other intermediaries if you incur administrative costs for processing the appeals and you report the cost on the Interim Expenditure Report (Form CMS- 1523). If an appellant submits one request involving several different claims (and several different beneficiaries), count it as one request. If an appellant submits more than one request (for different claims) at different times, count each request. NOTE: See definition of column (6) for instructions on hearings requested subsequent to OTR decisions. Line 4A. Medical Necessity Documentation Denials.--Show the number of requests included in line 4 that involved initial claim denials for lack of medical documentation. Line 5. Requests Transferred.--Show under columns 1 thru 5 the number of reconsiderations and review requests you transferred to other contractors because you did not process the original claim(s). Report under column 6 the number of Part B hearing requests transferred to other contractors because the claimant is not within your geographical area (See §3794.3B) or transferred to ROs because the issues are outside the HO's responsibilities. (See §3794.2.) For columns 1-6, if you have reported a reconsideration, review or Part B hearing as transferred, do not report any information regarding it on lines 6-51. The transfer is the final action. Line 6. Requests Cleared.--Show, under the appropriate columns, the total numbers of reconsiderations, reviews, and Part B hearings completed during the month. Report all completed appeals, regardless if final outcome was affirmation, reversal, withdrawal, or dismissal. Consider a reconsideration or review cleared when the final determination (EOMB or other notice, including dismissal) is printed or typed, or upon notification of withdrawal by the appellant. In the case of a reversal, consider the case cleared when you initiate the adjustment action. A Part B hearing may be considered cleared when the decision is signed, or the following conditions exist: o The claimant indicates that he/she is satisfied with the On-The-Record (OTR) decision; o The claimant indicates after the OTR decision that he/she wishes to proceed with an ALJ hearing (if the amount in controversy is $500 or more); o The HO dismisses the hearing request; or o The appellant withdraws the hearing request. Do not consider a hearing completed upon release of an OTR decision unless the appellant specifically requested an OTR hearing. Do not count the OTR hearing as completed until you have completed all follow-up actions as required in §3794.9. If as a result of the follow-up actions, the appellant requests an in-person or telephone hearing after release of the OTR decision, the OTR hearing and decision are not counted on the report with the exception noted below. If the appellant does not appear for the subsequent hearing, dismiss the hearing. (See §3794.3K.) For processing time purposes, the case is completed when you dismiss it; however, the decision to record in lines 9-11 is the OTR decision. NOTE: If you close a reconsideration, review or hearing after the end of a reporting month but before the report is due on the fifteenth of the subsequent month, do not count it until the subsequent month's report. Line 7. No. of Claims Involved.--Show on line 6 the total number of claims involved in the appeals reported as cleared during the month. For example, if you process one HHA reconsideration decision which involves five claims, report five claims under column (3), or if you process decisions for two Part B hearings in the month, one of which involved three claims and the other seven, report 10 claims under column (6). Line 8. Amount in Controversy.--For Part B hearings reported as affirmed (line 9) or reversed (line 11) during the month, show the total dollar amount in controversy on the initial requests. The amount in controversy is the difference between the amount billed (less any reductions required by legislation, e.g., Gramm-Rudman-Hollings) and the amount you originally allowed less any unmet deductible and coinsurance amounts. In effect, the amount in controversy is the amount of payment that the claimant would receive if the denial(s) was fully reversed. Show results rounded to the nearest dollar. Line 9. Affirmations.--Under the appropriate columns, show the number of completed reconsiderations, reviews, and Part B hearings in which the previous determinations were completely upheld; i.e., no change was made. All parts of all claims in a case must be upheld in order for the case to be counted as an affirmation. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, use the OTR decision to determine if the case is counted here. (See line 11 for partial affirmations. Do not include them here.) If you uphold your original determination, but pay under limitation of liability, count the determination as an affirmation. Report the appropriate information in Section D of the CMS- 2591. Line 10. Dism./Withdr.--Report, under the appropriate column, the number of completed reconsiderations, reviews, and Part B hearings that were withdrawn by the appellant or dismissed (before determination) by you or the HO. Report here and in lines 4 and 6 an appeal that is requested and withdrawn or dismissed within the same month. If the appellant requests an in- person or telephone hearing after receiving an OTR decision, and you dismiss the hearing because the appellant failed to appear, the OTR decision is the final decision, not the dismissal. Similarly, for a withdrawal, use the OTR decision. A dismissal at the reconsideration or review level is done when written correspondence has been identified as an appeal request, but the claimant does not have the right to an appeal. Misrouted correspondence and duplicate requests are not dismissals. If you have incorrectly counted such correspondence as an appeal on a previous report, use line 2 (adjustments to pending) to correct the count. Do not count a duplicate request for appeal anywhere on the report. Likewise, do not count on the report a request for appeal received before an initial claim determination has been rendered. (Consider the request an inquiry.) Line 11. Reversals (Full or Part).--Under the appropriate columns, show the total number of completed reconsiderations, reviews, and Part B hearings in which at least part of the prior determination was reversed. That is, a change was made and some or all of the new determination was in favor of the appellant. If a reconsideration, review, or Part B hearing involves several claims, and the initial determinations for some are affirmed and some are reversed, consider the decision a reversal. An OTR hearing decision does not count as a previous decision if the appellant subsequently requests an in-person or telephone hearing. If the in-person/telephone hearing is dismissed because the appellant did not appear, or the request was withdrawn, use the OTR decision to determine if the case is counted here. Line 12. Amount Awarded.--For cases included in line 11, show the amount of submitted charges for services where the determination was reversed. Show charges prior to application of the deductible and coinsurance. Round results to the nearest dollar. Processing and Pending Times.--This deals with processing and pending times for Part A and Part B appeals. Computing Time to Process Part A Reconsiderations and Part B Reviews for (Lines 13-18 and 25- 29) For lines 13-18 and 25-29, use the matrix below to determine the number of days from receipt to completion of reconsiderations and reviews. The date of receipt in all cases is the day the processing contractor received it in its corporate mailroom. Situation Date Completed • The appellant withdraws the request. The date you were notified of the withdrawal. • You dismiss the request or affirm the original determination. The date of the notice. • You process the request to a reversal. The date when you submit the claim to CWF if payment can be made without further development, or when you initiate development; e.g., when you must ascertain whether or not the provider has refunded payment to the beneficiary. Computing Time to Process Part B Hearings for Lines 35-39 For lines 35-39, use the matrix below to determine the number of days from receipt to completion of Part B hearings. The date of receipt, in all cases, is the day you receive the appeal request in its corporate mailroom. In out-of-area cases, it is the date that the second intermediary receives the request. Situation Date Completed An OTR decision is made and the appellant accepts the decision or decided to go directly to an ALJ hearing. The date of the OTR decision. An OTR decision is made and the appellant chooses in a timely fashion to proceed with the in- person or telephone hearing. The date of the second decision. If the appellant appears, and you dismiss the hearing, use the date of notice of dismissal. An in-person or telephone hearing is held without an OTR decision. The date of the decision. The appellant withdraws the hearing request. The date you are notified of the withdrawal. The HO dismisses the hearing request. The date of the dismissal notice. RECONSIDERATIONS Line 13. Processing Time - Average.--Report under the appropriate columns the average number of days from receipt of the reconsideration to the date of completion. To compute the average number of days from request to completion, divide the total days elapsed for all requests cleared in the month by the number of requests cleared. Round results to the nearest day. Calculate the days elapsed for an individual request by subtracting the Julian date of receipt from the Julian date of completion. If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as appropriate. (Otherwise, you will get a negative number.) If a case is cleared the same day it is received, consider it to require 1 day. NOTE: Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or withdrawn. Line 14. Reconsiderations Completed 1-45 Days.--Show the number of reconsiderations that required 1-45 days, to complete. If a case is cleared the same day it is received, consider it to require 1 day. Line 15. Reconsiderations Completed 46-60 Days.--Show the number of reconsiderations that required 46-60 days to complete. Line 16. Reconsiderations Completed 61-90 Days.--Show the number of reconsiderations that required 61-90 days to complete. Line 17. Reconsiderations Completed 91-120 Days.--Show the number of reconsiderations that required 91-120 days to complete. Line 18. Reconsiderations Completed over 120 Days.--Show the number of reconsiderations that required more than 120 days to complete. Line 19. Closing Pending Reconsiderations.--Show, under the appropriate columns, the total number of reconsiderations that have not been completed by the end of the reporting month. Line 20. Reconsiderations Pending 1-45 Days.--Show the number of reconsiderations included in line 19 that have been pending 1-45 days, inclusive, at the end of the reporting month. Line 21. Reconsiderations Pending 46-60 Days.--Show the number of reconsiderations included in line 19 that have been pending 46-60 days, inclusive, at the end of the reporting month. Line 22. Reconsiderations Pending 61-90 Days.--Show the number of reconsiderations included in line 19 that have been pending 61-90 days, inclusive, at the end of the reporting month. Line 23. Reconsiderations Pending 91-120 Days.--Show the number of reconsiderations included in line 19 which have been pending 91-120 days, inclusive, at the end of the reporting month. Line 24. Reconsiderations Pending Over 120 Days.--Show the number of reconsiderations included in line 19 which have been pending more than 120 days at the end of the reporting month. REVIEWS Line 25. Processing Time - Average.--Report here the average number of days from the receipt of the review to the date of completion. To compute the average number of days from request to completion, divide the total days elapsed for all requests cleared in the month by the number of requests cleared. Round results to the nearest day. Calculate the days elapsed for an individual request by subtracting the Julian date of receipt from the Julian date of completion. If the request is cleared in the year following the year of receipt, add 365 or 366 to the result, as appropriate. (Otherwise, you will get a negative number.) If a case is cleared the same day it is received, consider it to require 1 day. NOTE: Include all cases cleared, regardless of whether they were affirmed, reversed, dismissed, or withdrawn. Line 26. Reviews Completed in 1-30 Days.--Show the number of cases that required 1-30 days to complete. If a case is cleared the same day it is received, consider it to require 1 day. Line 27. Reviews Completed in 31-45 Days.--Show the number of reviews that required 31-45 days to complete. Line 28. Reviews Completed in 46-60 Days.--Show the number of reviews that required 46-60 days to complete. Line 29. Reviews Completed in 61+ Days.--Show the number of reviews that required more than 60 days to complete. Line 30. Closing Pending-Reviews.--Show the total number of reviews that have not been completed by the end of the reporting month. Line 31. Reviews Pending 1-30 Days.--Show the number of reviews included in line 30 that have been pending 1-30 days, inclusive, at the end of the reporting month. Line 32. Reviews Pending 31-45 Days.--Show the number of reviews included in line 30 that have been pending 31-45 days, inclusive, at the end of the reporting month. Line 33. Reviews Pending 46-60 Days.--Show the number of reviews included in line 30 that have been pending 46-60 days, inclusive, at the end of the reporting month. Line 34. Reviews Pending Over 60 Days.--Show the number of reviews included in line 30 that have been pending more than 60 days at the end of the reporting month. PART B HEARINGS Line 35. Hearing Processing Time - Average.--Report the average number of days from receipt of the hearing request to date of completion. See methodology under line 25. Line 36. Hearings Completed in 60 Days.--Show the number of hearings that required 1-60 days to complete. If a case is cleared the same day it is received, consider it to require 1 day. Line 37. Hearings Completed in 61-90 Days.--Show the number of hearings that required 61-90 days to complete. Line 38. Hearings Completed 91-120 Days.--Show the number of hearings that required 91-120 days to complete. Line 39. Hearings Completed Over 120 Days.--Show the number of hearings that required more than 120 days to complete. Line 40. Closing Pending-Hearings.--Show the total number of hearings that have not been completed by the end of the reporting month. You may not consider a hearing completed upon release of an OTR decision unless the appellant specifically requested an OTR hearing. See definition for line 6. Line 41. Hearings Pending 1-60 Days.--Show the number of hearings included in line 40 that have been pending 1-60 days, inclusive, at the end of the reporting month. Line 42. Hearings Pending 61-90 Days.--Show the number of hearings included in line 40 which have been pending 61-90 days, inclusive, at the end of the reporting month. Line 43. Hearings Pending 91-120 Days.--Show the number of hearings included in line 40 which have been pending 91-120 days, inclusive, at the end of the reporting month. Line 44. Hearings Pending Over 120 Days.--Show the number of hearings included in line 40 that have been pending more than 120 days at the end of the reporting month.