CMS Pub. 100-04, ch. 29, § 320.5

Once a party requests a reconsideration with a QIC, the QIC will need to obtain the case file from the

MAC that issued the redetermination decision. The foundation for an effective, efficient and

accurate appeals system is the case file. It is essential that the case file contain all relevant

information and evidence concerning an appeal in an organized manner so that the QIC can make a

correct and fair determination. The MAC prepares the case file by separating procedural documents

and medical documents and builds the case file from the bottom up, with the oldest set of documents

on the bottom, and the most recent set of documents at the top. However, it does not place the

medical documentation on the bottom. Medical documentation does not need to be ordered

chronologically, but rather can be included in the case file as submitted by the provider.

For large cases containing multiple beneficiary files, the MAC shall organize the case files by

individual beneficiary files in alphabetical order. A packing list will be included for multiple

beneficiary box cases and labeled as “box number x of y.”

As the MACs begin utilizing the MAS for processing redeterminations (timeframe by jurisdiction

TBD), the MACs shall work to update their JOAs with QICs to include language indicating that the

appeals case file will be obtained via electronic promotion of the level one appeal record within the

MAS. The MAC QIC JOAs shall include language to address situations in which the MAS is down

or otherwise unavailable for short term and/or long term periods of time. In addition, the JOA shall

include language to address processes and procedures for providing case files that are not in the

MAS due to the redetermination having been processed prior to the level one MAS implementation

and/or the rare instance that the file is otherwise not available in the MAS.

For one QIC case addressing multiple beneficiaries, particularly large multi-beneficiary and

overpayment cases, the MAC shall keep the documents relating to each beneficiary together and

organized alphabetically by beneficiary last name. Documents relating to each beneficiary will be

separated and a complete set of procedural documents will be provided for each beneficiary.

The following is a list of the documents generally included in any case file. Note that there may be

others not listed here. For applicable items, the MAC includes originals and retains hard copies of

any documents that are not available electronically for its records. Do not send abbreviated versions,

or versions of documents that the MAC has retyped or paraphrased for purposes of shortening the

document. The MAC must keep an exact copy of the file that is sent to the QIC. (Note: This

applies only when documents are not otherwise available electronically.) If it is unable to include

the original documents, it includes photocopies that are true facsimiles of the original documents. It

arranges the following documents, in descending date order (i.e., the claim form is on the bottom).

Procedural Documents:

• Claim form or printout, if electronically generated (facsimile and/or screen prints

are acceptable);

• MSN/RA - older files may contain EOMBs or Denial Letters, which must also be

included. (Facsimile and/or screen prints are acceptable);

• Redetermination request;

• Redetermination notice;

• Appointment of representative form (Form CMS-1696) or other written

authorization, if applicable;

• All documentation related to the assessment of an overpayment.

Medical Documents:

• Medical records, separated by facility, doctor, or location of service (separated by

a colored sheet or a sheet of paper with a heading);

• Referral to/from MAC medical staff (with professional qualifications of the

reviewer noted in the document, if applicable)

• MAC medical policies and opinions relevant to claim(s). (In addition to MAC

medical policy, the MAC should include in the case file any information it has as

background to the particular policy at issue. For example, findings of the MAC

advisory committee (CAC) with regard to the policy, including professional

publications relied upon to support the policy, opinions from professional medical

societies who may have commented on the policy during the development phase,

etc.) ( See the Program Integrity Manual, Pub. 100-08 for additional

information.);*

• A list of relevant portions of the law, regulations, CMS rulings, national coverage

determinations/decisions, and CMS manuals;

• Copies of LCDs, newsletters, any other pertinent information that may be used by

the QIC;*

• Any other exhibits that the MAC may consider important for the QIC to consider

(e.g., certification of reasonable charge, fee schedule information, notices of

noncoverage, MAC publications.); and

• Any additional evidence submitted by the appellant.

*If accessible by internet, the MAC that issued the redetermination decision may enter into a joint

operating agreement with the QIC to provide a list instead of actual copies.

Assembly Instructions:

• The MAC uses an appropriate file/folder/envelope which will contain necessary

documents in proper order, if the case file is not transmitted electronically.

• For combined requests filed by a beneficiary, the MAC keeps the documents

relating to treatment from each provider, physician, or supplier together. It

separates the documents relating to each provider, physician or supplier by a

blank sheet of paper;

• For combined requests filed by a provider, physician, or other supplier, the MAC

keeps the documents relating to each beneficiary together and organized

alphabetically by beneficiary last name. It separates the documents relating to

each beneficiary by a blank sheet of paper. It provides a complete set of

procedural documents for each beneficiary; and

• The MAC groups procedural documents together in chronological order and

groups medical documents together in chronological order.

Reconsideration Case Transmittal Form

The Reconsideration Case Transmittal Form documents the claim information and the date of the

redetermination. It also identifies the MAC that made the redetermination and the QIC with

jurisdiction for the reconsideration. The summary sheet should be placed on top of the documents in

the case file. The QIC will provide a Reconsideration Case Transmittal Form for use in the JOA.