CMS Pub. 100-10, ch. 7, § 7300

You are responsible for conducting DRG validation re-reviews. The authority for

reviewing changes in diagnostic and procedural coding information is found in 42 CFR

478.10(c).

A. Applicability

Although there are no reconsideration or appeal rights available for changes resulting

from DRG validation, the same process used for making a reconsideration determination

is used for DRG re-reviews (See §7430). A provider or practitioner dissatisfied with

your change to the diagnostic or procedural coding information is entitled to a review of

that change if it caused an assignment of a different DRG and resulted in a lower

payment (See 42 CFR 478.15(a)(1)). A beneficiary or his/her representative dissatisfied

with your change of the diagnostic or procedural coding information is also entitled to a

review of that change if it caused an initial denial of a furnished service (See 42 CFR

478.15(a)(2)). Review each case in its entirety.

B. How to Request a Re-review

The party must file a written request within 60 calendar days after the date of receipt of

the notice of change to the diagnostic or procedural coding information. A party may

also file such a request after 60 days for good cause (See §7410.C).

C. Qualifications of a Reviewer

The individual who reviews changes in DRG procedural or diagnostic information must

be a physician who meets the requirements in §7420.A. The individual who reviews

changes in DRG coding must be qualified through training and experience with ICD

coding. The reviewer (physician or non-physician) cannot be the person who made the

initial determination (A Registered Records Administrator or Accredited Records

Technician must have responsibility for the overall DRG validation process).

D. Timing of Re-review

Complete your re-review and send a written notice to all parties within 30 working days

of receipt of the request for a re-review.

E. Notices to Parties

Notify all parties (in writing) of your re-review determination. Be specific in explaining

the reason(s) for the changes (See Exhibit 7-47) (Do not send this notice to the

beneficiary). Notices of re-review must contain the following elements:

• A brief statement concerning your duties and functions under the Act, including

your responsibility to perform DRG validation;

• A listing of the ICD diagnosis and procedure code(s) and narrative description as

submitted by the provider and as originally changed by you, along with the reason

for the changes;

• A brief statement explaining that the provider and practitioner were given an

opportunity to provide additional information;

• The rationale used in upholding or reversing the initial DRG determination,

including the code(s) you finally determined to be correct upon re-review;

• A statement that the re-review determination is final (i.e., no further appeals

apply); and

• The signature, including title, of the medical director or designated physician if

the change(s) involve DRG procedural or diagnostic information (i.e., medical

judgment). If the change(s) involve(s) DRG coding errors, the re-review notice

may be signed by the medical director, designated physician, Chief Executive

Officer, Accredited Record Technician, or Registered Record Administrator (See

§7115.C.15).

7310 - Re-review of Quality Concerns - (Rev. 4, 07-18-03)

A. Applicability

Although no reconsideration rights are available for final quality concern determinations,

a physician or provider dissatisfied with your confirmed quality concern determination is

entitled to a review of that determination. The physician or provider does not need to

submit new information to be entitled to a re-review. This is an administrative appeal not

required by statute or regulation. No additional review or appeal beyond this re-review is

available for a confirmed quality concern determination.

B. Request for a Re-review

The physician or provider must file a written request for a re-review within 30 calendar

days after the date of the receipt of a notice of a confirmed quality concern determination

(Assume the date of receipt to be within 5 days of the date of the confirmed quality

concern notice if absent proof to the contrary). In the case of late filing, determine

whether the physician or provider has good cause for not requesting a re-review timely

(see §7420.C).

 Maintain a system for documenting your receipt of re-review requests. The

receipt date, unless otherwise proven, is the date recorded in your documentation

system.

C. Qualifications of Physician Reviewers Who Render Quality Re-review

Determinations

Physician reviewers conducting re-reviews must meet the requirements for physician

reviewers. Use a physician reviewer who was not involved in the determination of the

confirmed quality concern to perform the re-review.

D. Duties of Physician Reviewers Who Render Quality Re-review Determinations

Duties of physician reviewers include:

 Re-reviewing the original final determination about the quality concern, utilizing

the medical record, the PRAF 1, the PRAF 2, and any additional information

furnished by the physician or provider;

 Making a final determination regarding the quality concern(s) and the source(s) of

the quality concern(s); and

 Completing the PRAF for re-review (PRAF 3).

E. Timing of Re-review

Complete your review and send a written notice within 30 calendar days after you receive

the request for a re-review.

F. Notices to Parties

Issue a notice of a re-review determination for every case where a re-review is requested.

Send the re-review notice to the provider and to the physician(s) affected by your re-review determination.

G. Update of Data System

(e.g., for pattern analysis, internal quality control) when notices of re-review

determinations are sent out.

7400 - Statutory and Regulatory Requirements - (Rev. 4, 07-18-03)

Sections 1862 and 1155 of the Social Security Act (the Act) and 42 CFR Part 478 set

forth the appeals requirements applicable to your Part A and Part B initial denial

determinations by providing that a beneficiary, practitioner, or provider dissatisfied with

your initial denial determination involving medical necessity, reasonableness of services,

or appropriateness of setting is entitled to a reconsideration. A provider dissatisfied with

your initial denial determination involving circumvention of PPS (§1886(f)(2) of the Act)

is also entitled to a reconsideration.

Section 1879 of the Act (Limitation on Liability) and 42 CFR Part 405 Subpart G provide

that the beneficiary who has been found liable may obtain a reconsideration and appeal of

a Part A QIO determination. §1879(a) of the Act and 42 CFR Part 405 Subpart H

provide that the beneficiary who has been found liable may obtain a reconsideration and

appeal of a Part B QIO determination. If the provider or practitioner has been found

liable and the beneficiary has been found not liable, or if the beneficiary has been found

liable and does not pursue a reconsideration on the issue of knowledge, the provider or

practitioner may obtain a reconsideration on the issue that they did not know and could

not be expected to have known the services denied were not covered under Medicare Part

A and/or B. The criteria for determining beneficiary and provider/practitioner knowledge

are found in 42 CFR 411.404 and 411.406.

7410 - Requests for Reconsideration - (Rev. 4, 07-18-03)

A. Right to Request Reconsideration

A beneficiary, provider, or practitioner (including a practitioner who does not accept

assignment) may request a reconsideration regardless of whether there is a dollar amount

in controversy (e.g., a party may request a reconsideration when a case is paid under the

limitation on liability provision) (See 42 CFR 478.16).

NOTE: The term "party" is used throughout this chapter to mean a person (or group)

involved in a legal proceeding, usually the beneficiary, provider, and practitioner.

A beneficiary, provider, or practitioner dissatisfied with your denial determination may

obtain a reconsideration of the following issues:

 Reasonableness, medical necessity (including the need for using assistants at

cataract surgery), and appropriateness of the services furnished or proposed to be

furnished (e.g., whether treatment was appropriate for the condition) (See

§1862(a)(1) or (9) and §1154(a)(1)(A) of the Act);

 Appropriateness of the setting in which the services were, or are proposed, to be

furnished (See §1154(a)(1)(c) of the Act); and

 Whether financially liable under §1879 of the Act (Limitation on Liability):

• If the beneficiary (or the provider or practitioner) has been found liable by

you, the beneficiary may obtain a reconsideration of the liability

determination;

• If the provider or practitioner has been found liable, or the beneficiary has

been found liable but does not pursue a reconsideration on the issue of

knowledge, the provider or practitioner may obtain a reconsideration of

the liability determination; and

• If the practitioner has been found liable and the beneficiary has been found

not liable, or the beneficiary has been found liable but does not pursue a

reconsideration on the issue of knowledge, the practitioner may ask for a

reconsideration on the issue that neither the beneficiary nor the

practitioner knew and could not have known that the services denied were

not covered under Medicare Part B.

NOTE: When a reconsideration is conducted, make a determination on the issue of

knowledge. Providers/practitioners can only appeal the limitation on liability

determination, not the medical necessity determination, beyond the reconsideration.

A provider dissatisfied with your denial determination may obtain a reconsideration of a

Part A denial for circumvention of PPS as specified in §7440.

B. Timeframes To Request Reconsiderations

 Reconsiderations of Retrospective Initial Denials -- A beneficiary who is

dissatisfied with your initial denial determination may request a reconsideration

by writing to you, a SSA District Office, or a Railroad Retirement Board Office

(if the party is a railroad retirement beneficiary). A provider or practitioner may

request a reconsideration by writing to you. Reconsider an initial denial

determination if the beneficiary, provider, or practitioner files a timely written

request:

• Within 60 calendar days after receipt of the initial denial notice (except for

a request for expedited reconsideration under 42 CFR 478.18(c)). Receipt

of the notice is assumed to be within 5 days of the date of the initial notice

if absent proof to the contrary (See 42 CFR 478); or

• After 60 days, for good cause (See §7410.C).

 Expedited Reconsiderations of Preadmission/Pre-procedure (Including Assistant

at Cataract Surgery) Initial Denials -- A beneficiary, provider, or practitioner who

is dissatisfied with your initial denial determination may request an expedited

reconsideration by writing or telephoning you. Reconsider an initial denial

determination if the beneficiary, provider, or practitioner files a timely written or

telephone-expedited request within 3 calendar days after the date of receipt of the

notice of a preadmission/pre-procedure (including an assistant at cataract surgery)

denial. If an expedited reconsideration is not filed timely, a non-expedited

reconsideration may still be requested (See §7410.B.1).

 Expedited Reconsiderations of Concurrent Initial Denials -- A beneficiary,

provider, or practitioner who is dissatisfied with your initial denial determination

may request an expedited reconsideration through the hospital or by writing or

telephoning you. Reconsider an initial denial determination if the beneficiary,

provider, or practitioner files a timely expedited request at any time while the

beneficiary remains in the hospital. If an expedited reconsideration is not filed

timely, a non-expedited reconsideration may still be requested (See §7410.B.1).

C. Good Cause for Late Filing of a Request for a Reconsideration

In determining whether a party has shown that it had good cause for not filing a timely

request for reconsideration, consider, but do not limit your consideration to:

 The circumstances that kept a party from making the request on time;

 Whether your action(s) misled a party; and

 Whether a party did not understand the requirements for filing a timely request.

Examples of circumstances for which you may find good cause include:

 A party was seriously ill and was prevented from requesting a reconsideration;

 There was a death or serious illness in a party's immediate family;

 Important records were accidentally destroyed or damaged;

 A party made a diligent effort, but could not find or obtain the necessary relevant

information to support approval of the medical services before the deadline for

requesting reconsideration;

 A party requested within the applicable time limit additional information from

you explaining the action, and requested reconsideration within 60 calendar days

of receiving that information;

 The party was given incorrect or incomplete information by you about when and

how to request a reconsideration;

 A party sent the request within the time limit in good faith to another Government

agency, but the request did not reach the authorized office until after the time

period had expired; or

 Other unusual or unavoidable circumstances that show that a party could not have

known of the need to file timely or that prevented the party from filing timely.

7420 - QIO Reconsiderations - (Rev. 4, 07-18-03)

A. Qualifications of a QIO Reconsideration Reviewer

A QIO reconsideration reviewer must meet the qualifications required of a QIO physician

who makes an initial denial determination (See 42 CFR 478.28 and 42 CFR 476.98 for

the eligibility requirements for and responsibilities of physician reviewers, including the

obligation to consult with peers).

The physician reviewer must also be a board-certified or board-eligible specialist in the

same specialty as the physician whose services are being reviewed, and must be

practicing in a setting similar to that of the physician whose services are under review,

except:

 If use of a like specialist in a similar setting is impractical for a particular case,

use, if possible, a like specialist who practices in another setting.

 If it is impractical for you to meet the conditions listed above, use a board-certified specialist (or board candidate) in the specialty that matches the services

under review and who practices in a setting similar to that of the physician whose

services are under review. If this is impractical, use a physician reviewer whose

practice includes the services under review and whose practice is located in a

setting similar to that of the physician whose services are under review. When

this is not possible, document the reason(s) in the case file. Also, document the

physician reviewer's qualifications in the case file (See §7430.F).

The physician reviewer must not:

 Be the reviewer who made the initial denial determination;

 Have participated in developing or executing the beneficiary's treatment plan;

 Be in practice with any physician involved in the care of the beneficiary;

 Be a member of the beneficiary's family;

 Be a governing body member, officer, partner, 5 percent or more owner, or

managing employee in the health care facility where the services were or are to be

furnished; or

 Be a member of a reviewer's family, a spouse (other than one who is legally

separated under a decree of divorce or separate maintenance), a child (including a

legally adopted child), grandchild, parent, grandparent, or sibling.

NOTE: A beneficiary's attending physician may not request a specific reviewer to

conduct the reconsideration.

B. Finality of a Reconsidered Determination

Your reconsidered determination is final and binding upon all parties unless:

 Reopened and revised by you, either on your own motion or at the request of any

party within l year from the date of the reconsidered determination;

 Reopened and revised by you after l year, but within 4 years, because:

• You receive new and material evidence;

• There is a clerical error in the statement of your reconsidered

determination;

• You erred in interpretation or application of Medicare coverage policy; or

• There is an error apparent on the face of the evidence upon which your

reconsidered determination was based.

 Reopened and revised by you at any time if the reconsidered determination was

obtained through fraud or an abusive practice (e.g., describing services in such a

way that a wrong conclusion is reached); or

 Reversed after appeals filed in accordance with §7440. The Administrative Law

Judge (ALJ) or the Appeals Council, whichever made the final decision, may

reopen and revise its decision in accordance with the procedures set forth in 42

CFR 405.750(b)(1) and (2) which covers reopening and re-reviews under subpart

G of Part 405.

A reconsidered determination, a review of a DRG change, or a decision of an ALJ or the

Appeals Council may be reopened and reviewed at any time if the reconsideration

determination, review, or decision was obtained through fraud or a similar abusive

practice that does not support a formal finding of fraud.

7430 - Reconsideration Process - (Rev. 4, 07-18-03)

A. Provision of Information to Parties

Prior to the reconsideration, give all parties, upon request, an opportunity to examine or

obtain a copy of all the material upon which the initial denial determination was based,

including the complete medical record and summary of your findings and conclusions in

making the initial denial determination. Inform the requester that he may have to pay a

reasonable fee for the redaction of, reproduction of, and postage for, the material

requested (If patient information would be harmful to the beneficiary, provide it to the

beneficiary's designated representative upon receiving the request in writing pursuant to

42 CFR 480.132(c)).

In accordance with regulations governing disclosure of confidential QIO information and

regulations at 42 CFR 478.24(a), do not give a party access to:

 Your deliberations; and

 The identity of your review coordinators, physician advisors, or consultants that

assisted in reviewing the case (unless they have consented to release of their

names).

Establish and implement procedures to segregate your deliberations and identifiers from

the medical records when redacting.

No document or other information produced by you in connection with your deliberations

in making reconsiderations under Title XI of the Act shall be subject to subpoena or

discovery in any administrative or civil proceeding, except that you shall provide, upon

request of a practitioner or other person adversely affected by such a determination, a

summary of the organization's findings and conclusions in making the determination (See

§1160(d) of the Act).

B. Provision For Submittal of Additional Information from Parties

Give all parties the opportunity to present additional documentary materials (e.g., new

evidence) for consideration.

C. The Reconsideration Proceedings

Conduct the reconsideration proceedings as spelled out in your contract with CMS.

Conduct a medical records review at your office with no party being present, or conduct

proceedings similar to an evidentiary hearing. In either case, give the party advance

notice of the date of the reconsideration to allow sufficient time for submission of

evidence. Reschedule a reconsideration if a party submits a written request presenting

reasonable justification for rescheduling.

If your contract calls for an evidentiary hearing:

 Give any party the opportunity to ask reasonable questions (e.g., to clarify

information presented) of you or of any person who gives testimony; and

 Do not deny any involved party access to the hearing either while you present

information or while another party (or a witness) presents information.

You are not required to have your legal counsel attend even if legal counsel for a party

attends. In addition, you are not required to make a transcript of the reconsideration

proceedings. A summary of the proceedings is adequate.

D. Evidence at Reconsideration

Consider all information in the medical record, the basis for the initial determination, and

any additional evidence submitted by a party.

E. Areas of Consideration

Make a determination on medical necessity, reasonableness and appropriateness of

setting, and whether the beneficiary/physician/provider knew or should have known that

the care in question was not covered.

F. Timing of the Reconsidered Determination

Complete your reconsidered determination and send written notice within the timeframes

that follow:

 For preadmission or pre-procedure or assistant at cataract surgery reviews, within

3 working days after you receive the reconsideration request. Apply this

timeframe if the initial denial determination was made before the beneficiary was

admitted to the institution or before surgery was performed and a timely expedited

reconsideration request was made (see §7410.B.2).

 When the beneficiary is a hospital inpatient, within 3 working days after you

receive the reconsideration request. Apply this timeframe if the initial denial

determination was made while the beneficiary was still in the hospital and a

timely expedited reconsideration request was made (See §7410.B.3).

 When the beneficiary is an inpatient in a SNF or receiving home health agency

(HHA) services, within 10 working days after you receive the reconsideration

request. Apply this timeframe if the beneficiary is still an inpatient in a SNF for

the stay in question or is receiving home health services for the stay in question

when you receive the request.

 When the beneficiary is receiving non-institutional services, is no longer an

inpatient, or does not file a timely expedited request, within 30 working days after

you receive the reconsideration request. Apply this timeframe if the initial denial

determination concerns ambulatory or non-institutional services (except pre-procedure reviews), the beneficiary is no longer an inpatient in a hospital or SNF

and is not receiving home health services for the stay in question, or the party

does not file a timely request for expedited reconsideration (see §§7410.B.1 and

2).

Maintain a system, such as a log, for documenting your receipt of the request for

reconsideration. Receipt, unless otherwise proven, means the day that you have in your

records documentation that a notice was received. A party may request additional

information to further explain the determination within 30 working days, and may request

a reconsideration within 60 days of receiving the explanation (or within 30 days for an

Appeals Council hearing).

G. Notices of a Reconsideration Determination

Notices to Parties -- Notify all parties in writing of your reconsidered determination.

Discuss in detail the reasons for the initial and reconsidered determinations. Ensure that

the appellant understands the reason(s) for your determination and provide support for

your determination should the case be heard by an ALJ.

NOTE: Do not send beneficiaries or physicians reconsideration notices for

circumvention of PPS (See §7440 for further instructions for processing circumvention of

PPS reconsiderations).

All reconsideration notices must contain the following elements unless otherwise

specified (see Exhibits 7-40 through 7-50):

 A brief statement concerning your duties and functions under the Act (Cite the

regulatory basis for your review authority);

 The date that the reconsideration was requested and the party who requested it;

 The date of the admission or procedure, the name of the provider, and the reason

for the admission or the name of the procedure furnished;

 A detailed explanation of the reason for the initial denial determination. A

statement that the care was not medically necessary is not an adequate explanation

(see §7115.C.5);

 The qualifications of the physician(s) who reviewed the case at the

reconsideration level in a manner consistent with your disclosure requirements;

 A brief statement explaining that the provider and practitioner were given an

opportunity to provide additional information;

 A clear explanation of the reasons for the reconsidered determination, including a

narrative description of the medical facts and a detailed rationale for the

determination. Provide the appropriate statutory and regulatory citations. Include

an evaluation of any new points raised as part of the reconsideration request. If

no new points are raised, state this in your notice;

 A statement about each party's liability for payment. State the initial liability

determination for each party, including the rationale for each liability

determination. State the reconsidered determination for each party. Provide a

clear discussion of the Medicare payment consequences of the reconsidered

determination for the beneficiary, provider, and/or physician, including the

rationale for the liability determination;

 Fully document your determination that the beneficiary/provider/practitioner

knew or should have known that the care in question was not covered. The

following are examples of rationales that would support your liability

determination (see 42 CFR 411.406, §§7115.C.6 and 7):

• The beneficiary received written notice from you, the fiscal intermediary

(FI), carrier, utilization review committee, provider, or physician that the

services were not covered or that similar or reasonably comparable

services were not covered. Include a copy of the written notice in the

reconsideration notice; and

• The provider and/or physician had prior knowledge that the services

furnished were not covered or that similar or reasonably comparable

services were not covered based on experience, actual notice, or

constructive notice. This knowledge is based upon the provider's receipt

of CMS/QIO/FI/carrier notices (such as manual issuances, bulletins, or

other written guides or directives), medical review screening criteria

specific to the condition of the beneficiary for whom the furnished

services are at issue, or the provider's knowledge of what are considered

acceptable standards of practice by the local medical community. Provide

specific references and dates in the provider's and physician's rationale

(e.g., Bulletin #200, issued September 30, 1990).

 For denials based on circumvention of PPS, explain that the limitation on liability

provisions under §1879 do not apply, that the hospital is liable for the denied

charges, and that the beneficiary or his/her representative is only responsible for

payment of any applicable amounts for deductible, coinsurance, and convenience

services and items normally not covered by Medicare (see Exhibit 7-50);

 A statement regarding the indemnification of the beneficiary for provider and/or

physician services when the beneficiary has been found not liable (see §§7115C.8

and 9) (Include only if the initial denial is upheld or partially reversed. Do not

include in circumvention of PPS denials);

 If the beneficiary, provider, and/or physician has been found not liable, specify

that the beneficiary is responsible only for payment of any deductible,

coinsurance, and convenience services and items normally not covered by

Medicare for the denied period;

 If the provider and/or physician has been found liable and the beneficiary has

been found not liable, specify that the beneficiary is responsible only for payment

of any convenience services and items normally not covered by Medicare for the

denied period;

 Include the name, address, and telephone number of the FI and/or carrier where

the beneficiary can file a request for indemnification;

 Inform the beneficiary that if a request for indemnification is filed, a copy of the

denial notice, a copy of the bill for services, and a copy of the payment receipt

from the provider or any other evidence showing that the beneficiary paid the

provider must be provided to the FI or carrier;

 A statement regarding future liability (See §7115.C.10) (Include only if the initial

denial is upheld or partially reversed. Do not include in circumvention of PPS

denials);

 A complete discussion about further appeal rights of all parties (i.e., right to

request a hearing before an ALJ) (Include only if the initial denial is upheld or

partially reversed);

 Make it clear that beneficiaries may appeal the reasonableness, medical necessity,

or appropriateness of services furnished or proposed to be furnished, the

appropriateness of the setting in which the services were or are proposed to be

furnished, or whether they are liable for payment under §1879 of the Act

(Limitation on Liability). The provider and physician may only request a hearing

on the issue of knowledge under §1879. Providers may request a hearing on the

issue of circumvention of PPS (see §7410.A);

 State the minimum amount that must be in controversy to appeal your

reconsideration determination (see §7500);

 State that a written request for appeals (ALJ hearings) must be filed within 60

calendar days after receipt of a reconsideration determination;

 State that the request should include: the beneficiary's name, Medicare health

insurance claim number, where and when the services were received, the reason

for dissatisfaction with your determination, any additional evidence the

beneficiary, provider or physician wishes to submit, and a copy of the

reconsideration notice;

 State that a beneficiary may send an ALJ hearing request to you, any SSA District

Office, any Office of Hearings and Appeals (OHA), or a Railroad Retirement

Board Office (if eligible) and that a provider or practitioner may send an ALJ

hearing request to you or OHA (Do not include in circumvention of PPS denials);

 A statement regarding the beneficiary's or his/her representative's right to legal

representation (Include only if the initial denial is upheld or partially reversed.

Do not include in circumvention of PPS denials). Use the following language

without alteration:

• "If you want help with your appeal of this denial determination, you can

have a friend, lawyer or someone else help you. Some lawyers do not

charge unless you win your appeal. There are groups, such as lawyer

referral services, that can help you find a lawyer. There are also groups,

such as legal aid services, who will give you free legal services if you

qualify."

 A statement regarding the beneficiary's or his/her representative's right to examine

or receive a copy of the complete medical/clinical record (Include only if the

initial denial is upheld or partially reversed. Do not include in circumvention of

PPS denials). Use the following language without alteration:

• "You have the right to examine the complete medical record (and other

pertinent information) that we relied upon in making this denial

determination. Although the hospital is the official repository of the

medical records relevant to stays in the facility, should you wish to

examine the records and other pertinent information for this particular

stay, contact us at the address or telephone number listed above. There is

no charge to examine the material at our office. You may also request a

copy of the medical record and other pertinent information. We will,

however, charge you a reasonable fee for photocopying and mailing this

information."

 The signature of the medical director or designated physician (see §7115.C.15).

Notice to Payers -- Provide prompt written or electronic notification to the appropriate

Medicare FI or carrier of a reconsidered determination when the initial denial and/or

liability determination is partially or totally reversed. Include the name of the

beneficiary, the health insurance claim number, the name of the provider and physician,

date of admission, and dates of services, if any, for which Medicare payment will not be

made.

H. Record of the Reconsideration

Maintain the record (i.e., file) of your reconsideration until the later of 4 years after the

date on the notice of your determination or completion of litigation and the passage of the

time period for filing all appeals.

The record (file) must include:

 The initial denial determination and its basis (i.e., all documents associated with

the determination);

 A copy of the initial denial notice;

 Documentation of the date of the receipt of the parties' request for

reconsideration;

 Evidence submitted by the parties in support of the reconsideration request;

 The basis for the reconsidered determination;

 A copy of the reconsideration notice; and

 Documentation of when the initial denial and reconsideration notices were

given/mailed out to the parties (This may be written in a separately kept log).