CMS Pub. 100-04, ch. 30, § 120.5

Cases Conducted at the Request of Either the Beneficiary or the

Assignee

(Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07)

In every appeal where the limitation on liability provision is applicable, the

redetermination consists of two stages. The first stage is a new, independent and critical

reexamination of the facts regarding the coverage issue. If the original decision regarding

coverage was appropriate, the second stage is the decision whether to limit the liability of

the beneficiary and, if so, whether to also limit the liability of the provider, practitioner,

or supplier.

Redeterminations in assignment cases are conducted at the request of either the

beneficiary or the assignee. Frequently, the redetermination request is received from only

one of the parties, either the provider/physician/supplier or the beneficiary, and the only

notice to the other party that a redetermination has been requested is a copy of the

determination, i.e., after the fact. In a limitation on liability case, the parties may have

adverse interests in the limitation on liability decision, since a provider, practitioner, or

supplier may seek to show reason why the beneficiary’s liability should not be limited in

order to be able to collect his/her fee from the beneficiary. Therefore, when the contractor

receives a request for a redetermination, it sends a notice that a request has been filed to

the other party to the redetermination indicating that that party may submit additional

evidence. This is necessary to satisfy the statutory requirement that both parties be

informed of their rights and privileges in the appeal process.