Production of Medical Records and Documentation for an

4.7.4.1 - Production of Medical Records and Documentation for an Appeals Case File (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) When the UPIC denies a claim and the provider, supplier, physician or beneficiary appeals the denial, the MAC shall request the medical records and documentation that the UPIC used in making its determination. The UPIC shall assemble the case file and send it to the MAC within five (5) business days. If the MAC request is received outside of normal business hours or on an observed holiday that the UPIC is closed for business, the first business day will not be counted until the first business day after receipt of the request (i.e., if received on Saturday, the following Monday will be counted as the first business day). If the 5th business day falls on an observed holiday where either the UPIC or MAC is closed for business, documentation shall be sent on the next business day. The UPIC shall include any position papers or rationale and support for its decision so that the appeals adjudicator can consider it during the appeals process. However, UPICs shall be aware that an appeals case file is discoverable by the appellant. This means that the appellant can receive a complete copy of the case file. Since the provider may receive the case file, the UPIC shall consult with law enforcement before including any sensitive information relative to a case. When submitting documents to Office of Medicare Hearing and Appeals, UPICs shall use (OMHA's) e-Appeal Portal (Portal) for electronic submission of documents related to a Level 3 appeal. Submitting documents through the Portal is generally faster and more reliable than sending them via mail, fax, or email. Additionally, OMHA cannot accept documents containing Personally Identifiable Information (PII) and Protected Health Information (PHI) via email, so utilizing the Portal will resolve any concern about accidental, unsecure transmission of PII or PHI via email. Therefore, all UPICs shall use the Portal for electronic document submission. Examples of Level 3 Appeal related documents that UPICs shall upload to the Portal, as applicable, may include, but are not limited to Position Papers, Curricula Vitae (CVs), Evidence, Written Testimony, etc. Once uploaded to the Portal, these documents are automatically attached to the appeal in OMHA’s Electronic Case Adjudication and Processing Environment (ECAPE). The Portal provides immediate confirmation (on the website and via email) that submissions are received, and the ALJ team assigned to an appeal receives an alert whenever a document is uploaded to that appeal via the Portal. While the Portal shall be the primary method of document submission by the UPICs, circumstances may arise when the Portal is not available or practical. For example, on rare occasions, the Portal may be unavailable due to maintenance. In these circumstances, the UPICs may submit Level 3 Appeal related documents via email, fax, or mail, if all PII and PHI have been redacted or removed. The Portal is available at hhs-ecape-portal.entellitrak.com. To enter the Portal, UPIC representatives must first create an account. Refer to Exhibit 49.1 for instructions on How to Access the Portal. Once an account is created, the UPIC representative may upload relevant Level 3 Appeal documents. Refer to Exhibit 49.2 for instructions on How to Upload Documents Via the Portal. Note: Contractors and appellants may also use the Portal to check the status of an existing ECAPE appeal. If the UPIC would like to be notified of an Administrative Law Judge (ALJ) hearing on a particular case, the UPIC shall put a cover sheet in the case file before sending it to the MAC. The cover sheet shall state that the UPIC would like to be notified of an ALJ hearing and list a contact name with a phone and fax number where the contact can be reached. The cover sheet shall also include language stating, “PLEASE DO NOT REMOVE” to ensure it stays on the case file should the file be sent to the Quality Improvement Contractor. If the UPIC receives a notice of hearing, the UPIC shall contact the Qualified Independent Contractor (QIC) immediately. The QICs are tasked with participating in ALJ hearings; therefore, they are the primary Medicare contractor responsible for this function. UPICs may participate in an ALJ hearing, but they shall work with the QIC to ensure that duplicative work is not being performed by both the UPIC and the QIC in preparation for the hearing. UPICs shall never invoke party status. If the UPIC participates in a hearing, it shall be as a non-party. An ALJ cannot require participation in a hearing, whether it is party or non-party. If a UPIC receives a notice that appears contrary to this instruction, the UPIC shall contact the QIC and their BFL, with a copy to the COR, immediately.