CMS Pub. 100-04, ch. 34, § 10.13

Portal/Application to Support Reopening Activities

(Rev. 2241; Issued: 06-17-11, Effective: 10-01-11, Implementation: 10-03-11)

Contractors who develop and utilize a secure Internet portal/application for reopening

purposes shall ensure, at a minimum:

• CMS approves (i.e., Contract Manager or Project Officer, if applicable, and

Appeals Business Function Lead) the proposed portal/application and usage prior

to development and implementation.

• The portal/application fully complies and has been tested to ensure compliance

with all CMS system security requirements regarding protected health

information prior to implementation/usage.

• The secure Internet portal/application includes a formal registration process that

validates the signature. This process shall include, at a minimum, use of restricted

user identifiers (IDs) and passwords. Contractors shall include an indication

and/or description of the validation methodology in the appeals case file should an

appeal on the item/service reopened be requested.

• Templates for submission of electronic reopening request shall include, at a

minimum, a method for authenticating that the party has completed the

portal/application registration process and has been properly identified by the

system as an appropriate user.

• Contractors utilizing an approved portal/application shall provide education to

parties to the reopening regarding system capabilities/limitations prior to

implementation and utilization of the secure portal/application.

• Contractors shall also educate parties to the reopening that

participation/enrollment in the secure portal/application is at the discretion of the

party and the party bears the responsibility for the authenticity of the information

being attested to.

• Appropriate procedures are in place to provide parties with confirmation of

receipt of the reopening request via secure Internet/portal and verbiage instructing

the parties not to submit additional reopening requests for the same item or

service via different venue (hard copy mail or telephone).

• Contractors utilizing a secure portal/application shall ensure that there is a process

in place by which a party can submit additional documentation/materials

concurrent with the reopening request. The portal/application shall have the

capability to accept additional documentation and/or other materials to support

reopening requests.

• Refusal to reopen and adverse revised determination notices transmitted via a

secure Internet portal/application shall comply with the timeliness and content

requirements as outlined in the Pub. 100-04, chapter 34. In addition, contractors

shall provide hard copy decision notices to parties to the reopening, as required,

who do not have access to the secure Internet portal/application. The notices must

be mailed and/or otherwise transmitted concurrently (i.e., mailed on the same day

the notice is transmitted via the secure portal/application).

• Contractors utilizing a secure Internet portal/application shall include the adverse

revised determination/decision notice and any other related materials in the

appeals case file if a valid appeal on the item/service is later requested.

• Contractors shall also ensure that parties may save and print the revised adverse

determination/decision notice or refusal to reopen notice and that the secure

portal/application includes a mechanism by which the date/time of the notification

is tracked/marked both in the system and on any printed decision notices so as to

adequately inform the party of timeframes for ensuring timely submission of

future appeal requests.