Reconsideration - RO Procedures – Excluding SNFs and NFs

3054 - Reconsideration - RO Procedures – Excluding SNFs and NFs (Rev. 1, 05-21-04) 3054A - Review (Rev. 1, 05-21-04) A reconsideration is a thorough, independent review of the prior decision and entire body of evidence, including any new information developed. If the provider/supplier has made corrections since the survey on which the original determination was based and the SA can verify this, the provider/supplier may no longer wish to pursue its recommendation request. For initial certifications only, the potential provider/supplier may withdraw its reconsideration request, ask for another initial certification (as long as the timeframe for the Form CMS-855 application has not expired) and accept certification based on the date of compliance with all Medicare conditions. A reconsideration review is not complete unless and until every adverse finding (i.e., does not meet one or more statutory requirement, is not in substantial compliance with one or more CoPs) is adequately documented. The reconsideration process for nursing homes was eliminated in 1995 when Informal Dispute Resolution (IDR) was formalized as part of the appeals process for SNFs and NFs. IDR duplicates in every pertinent way the reconsideration element of this process sine it provides the opportunity for nursing home providers to conduct survey findings information (see §7212). 3054B - RO Receipt of Request (Rev. 1, 05-21-04) A provider or supplier of services which has been denied participation may file a request for reconsideration in any manner through any CMS RO, SA, or intermediary. The request may be in the form of a letter or statement and may be signed by any responsible official of the provider/supplier, or by an attorney on behalf of the provider. The RO officially dates or date-stamps any request the day of receipt in the RO. The request for reconsideration must state the issues or the findings of fact with which the affected party disagrees, and the reasons for disagreement. 3054C - Acknowledgment or Reconsideration Request (Rev. 1, 05-21-04) The RO acknowledges reconsideration requests within 3 working days of receipt. If an attorney filed the request, the RO sends a copy of the acknowledgment to the provider/supplier. If there is an offer to submit additional evidence or if the RO requests additional information, a reasonable deadline for its submittal is provided in the acknowledgment. The RO informs the provider/supplier that the SA may be in touch to obtain additional information. The RO informs the SA that the provider/supplier has requested reconsideration. 3054D - Reconsideration Determination (Rev. 1, 05-21-04) The RO completes a Certification and Transmittal, Form CMS-1539, except for Items 17 and 18 if the original determination is reversed. The RO marks the top of all copies of the form “Reconsideration - (Affirmed) or (Reversed)” and distribute the copies as in an initial decision. The RO does not need to complete Form CMS-1539 if the SA has made a revisit and the certification is based on the revisit. The SA in this case will complete Form CMS-1539. If OCR clearance has not yet been received, the RO advises OCR that a previously denied provider/supplier has now been approved so that they may complete the clearance process. The cover letter should request immediate return of the forms and point out that a final determination has not been made on the request for reconsideration. If any title VI forms are needed, they are sent with the agreement forms. 3054E - RO Notice of Reconsidered Determination (Rev. 1, 05-21-04) 3054E1 - Denial Reversal (Approval) (Rev. 1, 05-21-04) The RO confirms civil rights compliance before revising a denial of a provider on reconsideration. If the provider is not in compliance, see §2010. After confirming that documentation is in order, the RO assigns a provider identification number and completes a Certification and Transmittal, Form CMS-1539, marking item 30, “Reconsideration Reversed.” The RO issues a notice of acceptance as in a routine initial approval, enclosing the countersigned provider agreement. The notice of acceptance should reflect that the determination was reconsidered. The RO notifies the SA of the revised decision and sends a Provider Tie-In Notice, Form CMS-2007, to the intermediary. 3054E2 - Denial Affirmed (Rev. 1, 05-21-04) With the notice of decision, the RO includes a listing of each CoP, Condition for Coverage, or Requirement for SNFs with which the provider/supplier is not in compliance (for SNFs, substantial compliance). The RO includes a detailed explanation of why the deficiencies result in a determination and decision that the provider/supplier is not in compliance (substantial compliance for SNFs), the provider’s efforts and plans to correct deficiencies notwithstanding. The notice advises the provider/supplier of its rights to a hearing if it files a request within 60 calendar days of the date of receipt of the reconsideration decision of denial. The RO advises the provider/supplier to send the hearing request to it, Attn.: ARA, CMS. The RO forward all requests for hearings to the DAB for further action. The RO keeps a copy of the notice in the provider file and sends a copy to the SA. The RO acknowledges the receipt of the provider/supplier’s request for hearing in writing (see Exhibit 192). 3054E3 - Acting Official for Reconsideration Denial Notices (Rev. 1, 05-21-04) If a reconsideration request is denied, the reviewer who was assigned the initial determination should not sign the denial notices at the reconsideration level. • Initial Denial NOT Signed By ARA - If the ARA did not sign the initial denial notice he/she should sign the reconsideration denial notice. • Initial Denial Signed By ARA - If the ARA signed the original notification of denial, forward the file and formal recommendation to the RA. The notice of reconsideration denial is released over the RA’s signature. The RO notifies all interested components and prepares and transmits the required Form CMS-1539. • Problem Cases Needing CO Review - If the reconsideration action presents policy issues or problems that in the RO’s judgment need resolution, send the case to the CO with a statement of the problem and request guidance. The RO prepares and transmits Form CMS-1539 and adjudicative notices to the SMA, SA, and intermediary.