US · guidance
CMS Pub. 100-08, ch. 9, § 9.7
Appeals Resulting from RAC Initiated Denials
The MACs shall process any appeals stemming from a RAC improper payment (e.g.
RAC decisions appealed by the providers or beneficiaries) as any other appeal request.
Upon receiving an appeal request for a RAC improper payment, the MAC shall request
the medical records and any other supporting documentation from the RAC. The
timeframes regarding requesting and receiving medical records from the RAC shall be
agreed upon in the JOA. Even if the MAC believes they have enough documentation to
make a determination on the appeal, the MAC shall still request the medical records and
any other supporting documentation, as providers may submit different documentation to
the RAC than to the MAC upon appeal.
The MAC shall utilize the same approach in denying an appeal request (i.e. reopening or
redetermination) as used with any other appeal request. For more information on to
determine whether an appeal request should be processed as a reopening or
redetermination, MACs shall refer to the Medicare Claims Processing Manual (MCPM),
Publication 100-04, Chapter 34, Section 10.
History
(Rev. 921, Issued: 11-06-19 Effective: 11-04- 19, Implementation: 11-04-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
af34fab1ab8acea8ff101571335dd086ca3e4eba52aa3813dcd7ecda4b562778
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