CMS Pub. 100-04, ch. 29, § 310.6

A. Contractor Dismissal of a Redetermination Request

The contractor may dismiss a request for a redetermination under the following circumstances:

1. Request of a Party - A request for redetermination may be withdrawn at any time prior to the

mailing or transmission of the decision via a secure Internet portal/application upon the request of

the party or parties filing the request for redetermination. A party may request a dismissal by

filing a written notice of such request with the contractor. Contractors may accept requests for

withdrawal via facsimile and/or a secure Internet portal/application, if approved by CMS. The

dismissal of a request for redetermination is binding unless vacated by the contractor or QIC.

2. Dismissal for Cause - The contractor may dismiss a redetermination request, either entirely or as

to any stated issue, under either of the following circumstances:

a) Where the party requesting a redetermination is not a proper party, or

b) Where the party requesting a redetermination does not otherwise have a right to a

redetermination.

3. Failure to File Timely - When a request for redetermination is not filed within the time limit

required, and the contractor did not find good cause for failure to file timely, it should dismiss the

request.

4. Appointment of Representative is Defective - When an individual who is attempting to act as a

representative of an appellant who is not the beneficiary submits an incomplete appointment form

and the appointment is not corrected within the time limit discussed above in §270.1.6.B.1, the

contractor dismisses the request.

NOTE: If the appellant resubmits an appeal request with an appointment of representative form, the

contractor should consider the request as a duplicate and should not count the resubmission as

additional workload. (See Pub. 100-06, the Medicare Financial Management Manual, Chapter 6.)

5. Party Failed to Make A Valid Request - When the contractor determines the provider, supplier, or

State failed to make out a valid request for redetermination that substantially complies with

§310.1.B.1. or §310.1.B.2. A valid request may contain portions of the required information

within the documents or attachments submitted with the appeal, so that the request substantially

complies with the requirements established in 42 CFR 405.944. MACs shall not dismiss requests

under 42 CFR 405.952(b)(2) when redeterminations substantially comply with requirements.

6. Beneficiary Dies While the Request is Pending - When a beneficiary or the beneficiary’s

representative files a request for redetermination, but the beneficiary dies while the request is

pending, the contractor issues a dismissal when all of the following criteria apply:

a) The beneficiary's surviving spouse or estate has no remaining financial interest in the

case. In deciding this issue, the contractor considers if the surviving spouse or estate

remains liable for the services for which payment was denied or a Medicare contractor

held the beneficiary liable for subsequent similar services under the limitation on

liability provisions based on the denial of payment for services at issue;

b) No other individual or entity with a financial interest in the case wishes to pursue the

appeal; and

c) No other party filed a valid and timely redetermination request.

7. There is not an initial determination (see 42 CFR 405.924 and §200.B above for actions that are

initial determinations and 42 CFR 405.926 and §200.C above for actions that are not initial

determinations).

B. Appeal Rights for Dismissals

Parties to the redetermination have the right to request a QIC review of the contractor’s dismissal of

a redetermination request if they believe the dismissal is incorrect. The request for review must be

received by the QIC within 60 calendar days after receipt of the notice of dismissal. The date of

receipt of the notice of dismissal is presumed to be 5 calendar days after the date of the notice of

dismissal, unless there is evidence to the contrary. When the QIC performs its review of the

dismissal, it will decide if the dismissal was correct. If it determines that the contractor incorrectly

dismissed the redetermination, it will vacate the dismissal and remand the case to the contractor for a

redetermination. It is mandatory for the contractor to issue a new redetermination decision on any

case remanded by the QIC. The new decision is counted in CROWD on the 2590, 2591 and 2592 as

appropriate as a "redetermination”. A QIC’s review of a contractor’s dismissal of a redetermination

request is binding and not subject to any further review.

NOTE: QICs shall not include the “Important Information About Your Appeal Rights” insert when

issuing a decision on requests to review a contractor’s dismissal of a request for redetermination.

A party to the redetermination may also request that the contractor vacate its dismissal within 6

months of the date of the mailing (and/or other transmission if the contractor is utilizing a CMS

approved secure Internet portal/application) of the dismissal notice if good and sufficient cause is

established. If the contractor determines that there is good and sufficient cause, the contractor

vacates its prior dismissal and issues a redetermination. For the purposes of counting workload in

CROWD, this action should be counted as a redetermination and not a reopening. See §310.6.3

Processing Requests to Vacate Dismissals for more information.