CMS Pub. 100-04, ch. 29, § 250.2

As part of the requirements for a hearing or review before OMHA, a party to a proceeding must meet the

AIC provisions at 42 CFR 405.1006, including the threshold amount, as adjusted, in accordance with 42

CFR 405.1006(b).

The AIC is computed as the actual amount charged the individual for the items and services in question, reduced

by

(a) Any Medicare payments already made or awarded for the items or services; and

(b) Any deductible and coinsurance amounts that may be collected for the items or services.

In such cases where payment is made for items or services under section 1879 of the Act or under 42 CFR

411.400 or the liability of the beneficiary is limited under 42 CFR411.402, the AIC is computed as the

amount that the beneficiary would have been charged for the items or services in question if those expenses

were not paid under 42 CFR 411.400 or that the liability was not limited under 42 CFR 411.402, reduced by

any deductible and coinsurance amounts that may be collected for the items or services.

When a matter involves a provider or supplier termination of Medicare-covered items or services that is

disputed by a beneficiary, and the beneficiary did not elect to continue receiving the items or services, the

amount in controversy is calculated in accordance with 42 CFR 405.1006(d)(1), except that the amount

charged to the individual and any deductible and coinsurance that may be collected for the items or services

are calculated using the amount the beneficiary would have been charged if the beneficiary had received the

items or services the beneficiary asserts should have been covered based on the beneficiary's current

condition, and Medicare payment were not made for the items or services.

When an appeal involves an identified overpayment, the amount in controversy is the amount of the

overpayment specified in the demand letter for the items or services in the disputed claim. When an appeal

involves an estimated overpayment amount determined through the use of statistical sampling and

extrapolation, the amount in controversy is the total amount of the estimated overpayment determined

through extrapolation, as specified in the demand letter.

For appeals filed by beneficiaries challenging only the computation of a coinsurance amount or the amount

of a remaining deductible, the amount in controversy is the difference between the amount of the

coinsurance or remaining deductible, as determined by the contractor, and the amount of the coinsurance or

remaining deductible the beneficiary believes is correct.

For appeals of claims where the allowable amount has been paid in full and the appellant is challenging only

the validity of the allowable amount, as reflected on the published fee schedule or in the published

contractor-priced amount applicable to the items or services in the disputed claim, the amount in controversy

is the difference between the amount the appellant argues should have been the allowable amount for the

items or services in the disputed claim in the applicable jurisdiction and place of service, and the published

allowable amount for the items or services.

After processing the reconsideration, the QIC shall send written notification to all parties. This notice shall

include any information concerning the parties’ rights to an ALJ hearing, including the applicable AIC

requirements and aggregation provisions.