CMS Pub. 100-08, ch. 4, § 4.8.2

Appeals Case File

(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)

When the UPIC denies a claim and the provider, supplier, physician or beneficiary

appeals the denial, the MAC shall request the medical records and documentation that the

UPIC used in making its determination. The UPIC shall assemble the case file and send it

to the MAC within five (5) calendar days. If the MAC request is received outside of

normal business hours or on an observed holiday that the UPIC is closed for business, the

first calendar day will not be counted until the first business day after receipt of the

request (i.e. if received on Saturday, the following Monday will be counted as the first

calendar day).

The UPIC shall include any position papers or rationale and support for its decision so

that the appeals adjudicator can consider it during the appeals process. However, UPICs

shall be aware that an appeals case file is discoverable by the appellant. This means that

the appellant can receive a complete copy of the case file. Since the provider may receive

the case file, the UPIC shall consult with law enforcement before including any sensitive

information relative to a case.

If the UPIC would like to be notified of an ALJ hearing on a particular case, the UPIC

shall put a cover sheet in the case file before sending it to the MAC. The cover sheet shall

state that the UPIC would like to be notified of an ALJ hearing and list a contact name

with a phone and fax number where the contact can be reached. The cover sheet shall

also include language stating, “PLEASE DO NOT REMOVE” to ensure it stays on the

case file should the file be sent to the QIC. If the UPIC receives a notice of hearing, the

UPIC shall contact the QIC immediately.

The QICs are tasked with participating in ALJ hearings; therefore, they are the primary

Medicare contractor responsible for this function. UPICs may participate in an ALJ

hearing, but they shall work with the QIC to ensure that duplicative work is not being

performed by both the UPIC and the QIC in preparation for the hearing. UPICs shall

never invoke party status. If the UPIC participates in a hearing, it shall be as a non-party.

An ALJ cannot require participation in a hearing, whether it is party or non-party. If a

UPIC receives a notice that appears contrary to this instruction, the UPIC shall contact

the QIC and their primary BFL, with a copy to the COR, immediately.