BASIC (07-07)

A. Background

On March 8, 2005, CMS published an interim final rule that describes structural and procedural changes to the appeals process and how the changes will be implemented. The major areas affected are:

• The appeals process for claim denials required by section 521 of the Medicare Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA).

• The transfer of responsibility for the Medicare eligibility/entitlement ALJ function from the Social Security Administration (SSA) to the Department of Health and Human Services (HHS) as required by section 931 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), will begin July 1, 2005.

Redeterminations – First Level Appeals

One of the changes affecting SSA immediately is that all first level appeals (“redeterminations”) of initial determinations are subject to reconsideration by a new entity, a Qualified Independent Contractor (QIC).

• Beginning May 1, 2005, initial determinations made by fiscal intermediaries will be subject to QIC reconsiderations. These appeals generally involve Medicare Part A services, such as services furnished by hospitals, skilled nursing facilities, and home health agencies.

• Beginning January 1, 2006, initial determinations made by Medicare carriers of Medicare Part B claims (involving physician services and durable medical equipment items, for example) will be subject to QIC reconsiderations.

Hearings

• Effective July 1, 2005, the HHS Office of Medicare Hearing and Appeals will handle all hearings (including eligibility/entitlement issues) on a Medicare Part A, B, or C appeal.

Historically, SSA field offices have served as filing locations for claim appeals. In addition, callers to the 800 Number who wish to file an appeal were provided with the appropriate forms.

B. Medicare Part A and Part B – Appeals

It is no longer appropriate to file Medicare Part A appeals of initial determinations made after April 30, 2005, or Medicare Part B appeals of initial determinations made after December 31, 2005, at SSA Field Offices (FOs). Nevertheless, should a beneficiary seek assistance from SSA with their Medicare claim appeals, the following instructions are effective as indicated in the following:

FO/PSC action:

• If a Medicare beneficiary (or his/her representative) contacts SSA wanting to appeal:

  1. Ask if he/she has an initial determination, redetermination, QIC reconsideration, fair hearing decision, or an acknowledgement letter.

  2. If yes, direct the beneficiary to contact that person/entity shown on the document or forward the beneficiary’s inquiry to that person/entity. For example, if the Medicare beneficiary (or his/her representative) receives a letter that includes a Medicare Redetermination Notice (MRN) and wishes to file an appeal, forward both documents to the QIC indicated on the MRN.

  3. If no, and you cannot determine who the beneficiary should contact for assistance, direct him/her to call 1-800-Medicare (1-800-633-4227), and TTY users should call 1-877-486-2048.

• If SSA receives a written appeal request (redetermination, QIC reconsideration or ALJ appeal), forward it to the appropriate CMS Regional Office Appeals Contact (See HI 01205.005C., CMS Regional Office Appeals Contacts) within 5 days of the date that the request is received. Include a cover note (SSA-5002) indicating that the request was sent to SSA.

• Effective July 1, 2005, if SSA receives a written request for an ALJ hearing in a Medicare Part A, B, or C appeal, forward it to the appropriate HHS Office of Medicare Hearings and Appeals (See HI 01205.005D., HHS Office of Medicare Hearings and Appeals Locations) within 5 days of the date that the request is received. Include a cover note (SSA-5002) indicating that the request was sent to SSA.

• SSA will continue to perform initial and reconsideration determinations of health insurance eligibility/entitlement cases. However, effective July 1, 2005, HHS ALJs will hear appeals of those determinations. Therefore, effective July 1, 2005, when a request for an ALJ hearing is received in a health insurance eligibility/entitlement case, the case file should be forwarded to the appropriate Office of Medicare Hearings and Appeals (See HI 01205.005D., HHS Office of Medicare Hearings and Appeals Locations).

C. CMS Regional Office Appeals Contacts

D. Health and Human Services (HHS) Office of Medicare Hearings and Appeals Locations

The following are the HHS Office of Medicare Hearings and Appeals Locations.

http://www.hhs.gov/omha/contacts/offices.html

E. References

GN 03101.150A., Medicare Entitlement Appeals

GN 03102.425A.2. and GN 03102.425B.2., Reconsideration Notices of Determination

GN 03103.010B.6., The Hearing Process

TC 24030.010, Medicare Part A and Part B Claims Appeals (Hospital, Doctor and Medical Bills)