CMS Pub. 100-09, ch. 2, § 20.2.6

MACs shall provide clear and accurate responses to complex beneficiary inquiries within

25 business days for at least 75 percent of inquiries referred by the BCC or the CMS

ROs; and within 45 business days for 100 percent of all inquiries referred by the BCC or

the CMS ROs.

This timeframe begins the day the inquiry is originally received in NGD (transferred into

NGD) and ends the day the MAC sends the final response. For Benefit Integrity Unit

escalations, the MAC shall consider the action complete and close the complex inquiry in

NGD when the Benefit Integrity Unit referral is placed into the second-level screening

work flow, and not when the second-level screening is complete.

For those complex beneficiary inquiries that cannot be answered in final within 45

business days, MACs shall send an interim response acknowledging receipt of the inquiry

and explaining the reason for the delay. When possible, inform the beneficiary about

how long it will be until a final response will be sent. Sending an interim response does

not resolve the issue and the inquiry is not considered closed until the final response is

sent.

The final response shall be sent within 5 business days after receipt of the needed

information. Any interim responses for complex beneficiary inquiries will count toward

the MAC’s overall allowance of no more than 5 percent of interim responses for the

universe of complex beneficiary inquiries. Responses to complex beneficiary inquiries

shall be documented in NGD.