CMS Pub. 100-04, ch. 29, § 310.4

A. Timely Processing Requirements

The contractor must complete and mail a redetermination notice for all requests for redetermination within

60 days of receipt of the request (with the exception of (D)(4) below). The date of receipt for purposes of

this standard is defined as the date the request for redetermination is received in the corporate mailroom or

the date when the electronic request for appeal is received via facsimile or through the secure Internet

portal/application. For misfiled redetermination requests, the proper contractor jurisdiction must complete

and mail a redetermination notice within 60 days of receiving the misfiled request in their corporate

mailroom.

Completion means:

1. For affirmations (unfavorable decisions), the date the decision letter is mailed to all of the parties

(or their representatives). Affirmations processed via a CMS approved secure Internet

portal/application shall be considered complete on the date the electronic redetermination notice is

transmitted to the appellant through the secure Internet portal/application, and a hard copy decision

letter is sent to other parties to the appeal who do not have access to the secure Internet

portal/application. See §310.10 for additional requirements related to notices sent via secure

portal/applications.

2. For partial reversals (partially favorable decisions) and full reversals (fully favorable decisions),

when all of the following actions have been completed:

a. The decision letter, if applicable, is mailed to the parties. If the redetermination is processed via a

CMS approved secure Internet portal/application, it shall be considered complete on the date the

electronic redetermination notice is transmitted to the appellant through the secure Internet

portal/application, and a hard copy decision letter is sent to other parties to the appeal who do not

have access to the secure Internet portal/application. See §310.10 for additional requirements related

to notices sent via secure portal/ applications, and

b. The actions to initiate the adjustment action in the claims processing system are taken. When the

adjustment action is completed, this action must be included on the next scheduled release of the

MSN/RA. Appropriate follow-up action should be taken to ensure that the adjustment action results

in the issuance of proper payment.

3. For withdrawals and dismissals, the date the dismissal notice is mailed. If the redetermination is

processed via a CMS approved secure Internet portal/application, it shall be considered complete on

the date the notice is transmitted to the appellant through the secure Internet portal/application, and

a hard copy decision letter is sent to other parties to the appeal who do not have access to the secure

Internet portal/application. See §310.10 for additional requirements related to notices sent via

secure portal/applications.

B. Development of the Appeal Case File

The reviewer must obtain and review all available and relevant information needed to make the

determination. All information considered by the appeals adjudicator in conducting the redetermination

must be included in the case file. Other areas within the contractor may have information relevant to the

claim(s) at issue. For example, the medical review area may submit evidence to the reviewer for inclusion

in the case file (e.g., documentation and correspondence related to provider education on the issues

appealed, any notices of review, and specific documentation requests to the provider and third parties).

In addition, contractors such as Recovery Audit Contractors (RACs), UPICs, or the Supplemental Medical

Review Contractor (SMRC) may have other information from their review of claims that they wish to

include in the case file. Documentation submitted by a provider, supplier or beneficiary (or other party to

the appeal) as part of a prepayment (e.g. medical review or demand bill review) or postpayment (e.g. UPIC

reviews) review, including clinical documentation, must be included in the appeals case file for

consideration during the redetermination.

If this documentation is not included in the appeals case file, the reviewer shall request the documentation

from the claims review contractors (i.e., RACs, UPICs, and SMRCs) prior to rendering the redetermination

decision. The timeframes associated with request and delivery of medical records from the CMS claims

review contractor to the MAC should be agreed upon in the Joint Operating Agreement (JOA). The MACs

should notify the respective Contracting Officer’s Representative if there is any difficulty obtaining

documentation from the CMS contractors within the agreed upon timeframes established by the JOA.

If the claims review contractor confirms that it did not receive medical records from the provider, supplier,

or beneficiary (or other party to the appeal) or the information is otherwise unavailable, and the

documentation is needed to support a favorable resolution of the appeals case, then the MAC shall reach out

to the provider, supplier, beneficiary (or other proper party to the appeal) to obtain the medical records, and

any other supporting documentation, prior to rendering the redetermination decision. The case file and

redetermination decision letter shall document all attempts to obtain the medical records and/or any other

support documentation prior to rendering the redetermination decision.

The development of the case file is important not only for the redetermination, but also to prepare for a

potential appeal to the QIC. Proper development of the case file will assist the contractor in timely

transmitting the case file to the QIC upon request. In instances of large overpayment cases involving many

claims, this case file development is extremely important.

For example, with respect to overpayments that are determined through statistical sampling and

extrapolation, appellants often challenge the sampling methodology and the extrapolation during the

reconsideration or an ALJ hearing. To avoid any documentation issues during subsequent appeals,

contractors shall include all information detailed in IOM 100-08, Chapter 8, §8.4.4 related to the sampling

methodology and extrapolation in the case file.

When a reconsideration request is filed with the QIC, and the QIC requests a case file for a large

overpayment case, it is critical the QIC obtain the case file timely so it can begin adjudication. Therefore, it

should be a priority for the contractor to adequately develop case files.

Evidence in the case file must be made available for inspection by an appellant or party upon request.

Reviewers must exercise care in determining the weight to give allegations of fraud and abuse where the

source of the specified information is not provided. Although the name of the beneficiary or other source

that provided the information that triggered an investigation is not always provided or necessary when

reviewing the evidence, the case file must include information on the independent, subsequently developed

investigation that supports the claim decision (See subsection D, below, for instructions on development of

documentation.)

C. Conducting the Redetermination

1. Overview

• The redetermination is an independent review of an initial determination. The individual

performing the redetermination must not be the same person who made the initial determination.

• The contractor reviews the evidence and findings upon which the initial determination was based,

and any additional evidence the parties submit or the contractor obtains on its own.

• For redeterminations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor, MACs shall limit their

review to the reason(s) the claim or line item at issue was initially denied. Prepayment reviews occur

prior to Medicare payment, when a contractor conducts a review of the claim and/or supporting

documentation to make an initial determination. Post-payment review or audit refers to claims that

were initially paid by Medicare and subsequently reopened and reviewed by, for example, a UPIC,

RAC, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage,

change coding, or reduce payment. Complex reviews require a manual review of the supporting

medical records to determine whether there is an improper payment.

Automated reviews use claims data analysis to identify improper payments. If an appeal involves a

claim or line item denied on an automated pre-payment basis, MACs may continue to develop new

issues and evidence at their discretion and may issue unfavorable decisions for reasons other than

those specified in the initial determination.

Contractors will continue to follow existing procedures regarding claim adjustments resulting from

favorable appeal decisions. These adjustments will process through CMS systems and may suspend

due to system edits. Claim adjustments that do not process to payment because of additional system

imposed payment limitations, conditions or restrictions (for example, frequency limits or National

Correct Coding Initiative edits) may result in new denials with full appeal rights (i.e., the new denial

will be considered an initial determination with respect to the appeals process).

If a MAC conducts an appeal of a claim or line item that was denied on pre- or post-payment review

because a provider, supplier, or beneficiary failed to submit requested documentation, the MAC will

review all applicable coverage and payment requirements for the item or service at issue, including

whether the item or service was medically reasonable and necessary. As a result, claims initially

denied for insufficient documentation may be denied on appeal if additional documentation is

submitted and it does not support medical necessity.

• There may be times where the appellant requests a redetermination of an entire claim and there may

be times where he/she requests a redetermination of a specific line item on the claim. The contractor

should review all aspects of the claim or line item necessary to respond to the appellant’s issue. For

example, if the appellant questions the amount paid, the contractor must also review medical

necessity, coverage, deductible, and limitation on liability, if applicable.

• If the appellant requests a redetermination of a specific line item, the contractor reviews all aspects

of the claim related to that line item. If appropriate, it reviews the entire claim. If it reviews more

than what the appellant indicated, it includes an explanation in the rationale portion of the

redetermination letter of why the other service(s)/item(s) were reviewed.

2. [Reserved]

3. Appeal Requests Filed on Resubmitted Claims

For appeals of a specific line item or service, the date of the first MSN or RA that states the coverage and

payment decision is the date of the initial determination. Adjustments to the initial claim or claim

resubmissions for the same item/service on the same date of service that are included on subsequent MSNs

or RAs, but do not revise the initial determination, do not extend/change the appeal rights on the initial

determination.

4. Fraud

Although the reviewer may not make a finding of criminal or civil fraud (see §280, “Fraud and Abuse”), the

reviewer should review the claim to see if there is sufficient documentation and evidence supporting that the

items or services were actually furnished or were furnished as billed.

5. Appeals Involving Overpayments

For appeals that involve overpayments, the contractor shall review all aspects of the overpayment, including

the validity of the overpayment, whether the amount of the overpayment was correctly calculated and

extrapolated (if applicable), who is responsible for the overpayment, and whether recovery of the

overpayment should be waived under §1870 of the Act. For additional information see IOM 100-06 Chapter

3, sections 70 through 110.

If the redetermination involves an extrapolated overpayment and the appellant challenges the validity of the

sampling methodology, the contractor reviews the claims in question as well as the methodology used to

extrapolate the overpayment amount. For background on how the UPICs use statistical sampling to estimate

overpayments, see IOM 100-08, Chapter 8, section 8.4. If a reconsideration is subsequently requested, the

entire case will be sent.

6. Evidence

Appellants have the opportunity to submit written evidence and arguments relating to the claim at issue.

Contractors must accept and consider any relevant documentation submitted. Contractors may also accept

this information via facsimile and/or a secure Internet portal/application.

D. Requests for Documentation

1. Requesting Documentation for State-Initiated Appeals

The reviewer should not request documentation directly from a provider or supplier for a State- initiated

appeal. If additional documentation is needed, the reviewer should request that the submitter of the appeal

(i.e., the State or the party authorized to act on behalf of the Medicaid State Agency) obtain and submit

necessary documentation. The requested documents may be submitted via facsimile or via a secure Internet

portal/application. Documentation previously submitted by the State or the provider/supplier as part of a

demand bill review must be included in the appeals case file for review during the redetermination (see

§310.4.B).

2. Requesting Documentation for Provider or Supplier-Initiated Appeals

For provider and supplier initiated appeals, when necessary documentation has not been submitted, the

reviewer advises the provider or supplier to submit the required documentation. The reviewer notifies the

provider or supplier of the timeframe the provider or supplier has to submit the documentation. The

reviewer documents the request in the redetermination case file. The requested documents may be

submitted via facsimile and/or via a secure Internet portal/application. In some situations, a provider or

supplier may inform the reviewer that it is having trouble obtaining supporting documentation from another

provider or supplier (e.g., an ambulance supplier who is requested to submit hospital admission records). In

this situation, the contractor may assist the provider or supplier in obtaining records. If the additional

documentation that was requested is not received within 14 calendar days from the date of request, the

reviewer conducts the redetermination based on the information in the file. The reviewer must consider

evidence that is received after the 14-day deadline but before having made and issued the redetermination.

See §310.4.D.4 below for information on the extension of the decision making timeframe for additional

documentation that is submitted after the request.

3. Requesting Documentation for Beneficiary-Initiated Appeals

For beneficiary initiated appeals, when necessary documentation has not been submitted, the reviewer

advises the provider or supplier to submit the required documentation. The reviewer documents the request

in the redetermination case file. The reviewer notifies the beneficiary (either in writing or via a telephone

call) when the reviewer has asked the beneficiary’s provider or supplier for additional documentation. The

reviewer also notifies the beneficiary that the provider or supplier has 14 calendar days to submit the

additional documentation that has been requested, and that if the documentation is not submitted, the

reviewer will decide based on the evidence in the case file. If the reviewer sends the beneficiary a letter, it

must include a description of the documentation that has been requested. The reviewer shall document all

notifications and correspondence to and from the beneficiary in the redetermination case file.

4. Extension for Receipt of Additional Documentation

Contractors shall educate parties to include all supporting documentation with the redetermination requests

submitted via mail, facsimile or a secure Internet portal/application. However, when a party submits

additional evidence (via mail, facsimile or a secure Internet portal/application) after filing the request for

redetermination, the contractor’s 60-day decision- making timeframe is automatically extended for up to 14

calendar days for each submission.

This additional time is allowed for all documentation submitted by a party after the request, even when the

documentation was requested by the contractor. Although this extension is granted to the contractor for

making decisions, it should not routinely be applied unless extra time is needed to consider the additional

documentation.

5. General Information

The contractor routinely includes instructions on the appropriate information to submit with appeal requests

in its provider newsletters and other educational literature. Providers and suppliers are responsible for

providing all the information the contractor requires to adjudicate the claim(s) at issue.