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Sunday, June 6, 2010

Medicare 2nd level appeal - Reconsideration

If the contractor rules negatively concerning the redetermination, a Qualified Independent Contractor (QIC)
will handle the next level of appeal. The QICs are divided by geographic region. Currently, there are five QICs—two for Part A, two for Part B, and one DME contractor. The QIC carries out an independent investigation and analysis of previously submitted documentation from the initial determination and the redetermination. National coverage determinations, CMS rulings, and applicable laws are binding on the QICs. They are not bound by “local coverage determinations, CMS program guidance, such as program memoranda, and manual instructions, but give substantial deference to these policies if they are
applicable to a particular case.” CMS requires the QIC to follow CMS regulations, except when an appellant proves reasonably to the QIC that an LCD or NCD does not apply to the coverage rationale. If the QIC agrees with the appellant’s rationale, it must state the reason behind this decision.

If the redetermination was denied based on medical necessity, the QIC designates a panel of physicians or other appropriate healthcare professionals to review the case. If the claim involves physician
services, the personnel who review the case must include a physician. Providers have 180 days to file reconsiderations from the date of receipt of the RA or Medicare Redetermination notice (MRN).
You can file the reconsideration on the standard form CMS 20033; alternatively, you can send a written request, which must contain patient identifying information (same as preceding level), and the
name of the contractor that made the redetermination. Any evidence that is not submitted by this level will be dismissed if introduced in subsequent levels without good cause.

If you are unable to meet the deadline for filing the reconsideration, as in the previous level, you must show good cause for an extension in writing (see above). The QIC will make his/her decision on the reconsideration at least 60 days after receiving all the necessary information. If the QIC is unable to meet the decision deadline, CMS requires the contractor to contact the parties involved (in writing) explaining this inability and informing them of their rights to escalate the case to an Administrative Law Judge (ALJ). If the decision is not favorable, the QIC will inform the appellant of its decision and the next level of appeal, if the amount in  controversy (AIC) for the denied claim is over $120. According to CMS, “the AIC increased by the  percentage increase in the medical care component of the consumer price index for all urban consumers.
We will update our website annually with the AIC.”

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