CMS Pub. 100-04, ch. 29, § 310.6.1

The MAC shall issue in writing and/or otherwise transmit, as noted above, a notice of dismissal to all parties

to the appeal. The dismissal notice includes the reason for the dismissal. The dismissal notice must inform

parties that they may (1) request the MAC to vacate the dismissal, and (2) may request a QIC

reconsideration of the dismissal. The dismissal notice is sent to the party requesting the redetermination at

his/her last known address, and/or otherwise transmitted as noted above, as well as to his/her representative

and all other parties to the appeal. MACs who utilize an approved CMS secure Internet portal/application to

receive and process appeals may provide electronic dismissal notices, if the appeal request was received via

a secure portal/application. MACs shall ensure that a hard copy dismissal notice 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.

MACs shall include the following language, or something similar, in dismissal letters (also see the model

dismissal letters in Exhibits 2&3):

If you disagree with this dismissal, you have two options:

1. You may request that we vacate our dismissal. We will vacate our dismissal if you demonstrate

good and sufficient cause for <insert reason for dismissal>. Your request to vacate this dismissal

must be received at our office within 6 months of the date of receipt of this notice at the address

noted above.

2. If you think we have incorrectly dismissed your request (for example, you believe <insert reason

(e.g., you did file your request on time, you were a proper party, the MAC did issue an initial

determination on the claim)>), you may request a reconsideration of the dismissal by a Qualified

Independent Contractor (QIC). Your request must be received by the QIC at the address below

within 60 days of receipt of this letter. In your request, please explain why you believe the

dismissal was incorrect. The QIC will not consider any evidence for establishing coverage of the

claims(s) being appealed. Their examination will be limited to whether or not the dismissal was

appropriate. Please send your request to:

Insert QIC Address

Incomplete Requests - The requirements for written requests for redetermination are found in §310.1.B.2.

NOTE: Beneficiary requests should not be considered incomplete, see §310.1.B.1 and §310.1.B.3.

MACs must handle and count incomplete redetermination requests as dismissals. If a party submits an

incomplete request for redetermination and the MAC issues a dismissal notice, the party may request the

dismissal be vacated, the party may appeal the dismissal, or the party may refile their request if any time

remains in the filing period (i.e., 120 days from receipt of the initial determination). When a request is

refiled that meets the requirements, the previous dismissal is vacated and reopened. MACs must notify

parties of their options in the dismissal notice. Please see the model dismissal notice for an incomplete

request in §310.6.2.