Monday, August 5, 2013


A Request for Reconsideration (Appeal) is a written request by a Medicare HMO member (his/her legal guardian,  authorized  representative,  or  power  of  attorney),  or  a  non-participating  provider,  (who  has signed  a  waiver  indicating  he/she  will  not  seek  payment  from  the  member  for  the  item  or  service  in question). A physician who is providing treatment to a member, upon providing notice to the member, may  request  an  expedited  or  standard  reconsideration  on  the  member’s  behalf  without  having  been appointed as the member’s authorized representative.

To reconsider Plan’s Initial Determination to deny payment of a claim or authorize a service, a request for reconsideration must be received within sixty (60) calendar days of receipt of an initial determination. A decision on a request for reconsideration must be expedited as the member’s health condition requires, but  no  later  than  72  hours  for  situations  where  applying  the  standard  time  procedure  could  seriously jeopardize the enrollees life, health or ability to regain maximum function, thirty (30) calendar days for a standard service request and sixty (60) calendar days if the request is for the Payment of a denied claim.

Formal Appeal Process:
There are six (6) levels of the Appeals process:

1.  The initial determination (organization determination)
2.  Appeal Reconsideration.
3.    Reconsideration by the Independent Review Entity:  MAXIMUS Federal Services, Inc.
4.  Hearing  by  an  Administrative  Law  Judge  (ALJ),  if  at  least  $140.00  (amount  in  2013)  is  in controversy.
5.  Medicare Appeals Council (MAC);
6.  Judicial review, if at least $1,400.00 (amount in 2013) is in controversy.

Appeal Reconsideration:
A Request for Reconsideration (Appeal) is received within sixty (60) calendar days of the adverse initial determination.  A Medicare member can also appeal through the local Social Security (SSA) office or Railroad Retirement Board (RRB) office (if member is a railroad annuitant). 

The  Grievance  &  Appeals  Correspondence  Specialist  assigns  the  case  to  the  Grievance  &  Appeals Specialist for research. The Grievance & Appeals Specialist acknowledges the request for reconsideration (appeal)  within  five  (5)  calendar  days  of  receipt.  If  a  member’s  issue  involves  both  an  appeal  and grievance, they are worked simultaneously.

In all cases, payment of claims or authorization for services and notification to member/non-contracted provider must be made within, 72 hours for expedited request, thirty (30) calendar days for a standard request for a service and sixty (60) calendar days for payment of a denied claim.  If sufficient information to  make  a  determination  is  not  received  within  the  allowed  processing  time,  a  determination  must  be made based on the information received. (An extension of up to fourteen (14) calendar days can be made if requested by the member or if the plan justifies the need for additional information and it is in the best interest of the member).  Members will be advised of their right to file an expedited grievance should they not agree to the extension.

If a decision cannot be made or if the denial is upheld in whole, or in part, the entire file is forwarded along  with  written  explanation  of  the  decision  to  MAXIMUS  Federal  Services,  Inc.  for  a  new determination  by  the,  72
nd  hour,  30th  or  60th  day.    The  member/appointed  representative/treating physician/non-contracted provider is notified verbally and followed-up in writing.

MAXIMUS advises the member/appointed representative/treating physician/non-contracted provider and the plan of its decision in writing within the required time frames depending on the level of the appeal stating the reason(s) for the decision and inform the member/non-contracted provider of his or her right to a  hearing  before  an  Administrative  Law  Judge  of  the  Social  Security  Administration  if  the  denial  is upheld and the amount in controversy meets the appropriate threshold requirement.
If the denial is overturned by MAXIMUS, the request for a service is provided as expeditiously as the member’s  health  requires  but  no  later  than  72  hours  for  an  expedited  appeal,  14  calendar  days  for  a standard service appeal or 30 calendar days for a standard claim appeals.

If the amount in controversy is at least $140.00 in 2013, the member/non-contracted provider may appeal MAXIMUS' decision by requesting a hearing before an Administrative Law Judge (ALJ). The request must be submitted in writing within sixty (60) days after the date of notice of the adverse reconsideration determination  and  must  be  filed  with  the  entity  specified  in  MAXIMUS'  reconsideration  notice.  If CarePlus  receives  a  written  request  for  an  ALJ  hearing  from  an  enrollee,  CarePlus  must  forward  the enrollee's request to MAXIMUS.

An adverse decision or case dismissed by the ALJ can be reviewed by the Medicare Appeals Council (MAC), either by its own action or as the result of a request form the member/non-contracted provider or CarePlus.  If the MAC grants the request for review, it may either issue a final decision or dismissal, or remand the case to the ALJ with instructions.  MAC review must be requested in writing within sixty (60) days of the ALJ adverse determination.

If the amount remaining in controversy is at least $1,400.00 in 2013, the member/non-contracted provider of CarePlus may request a Judicial Review. The review must be requested in writing within sixty (60) days of the MAC’s adverse determination.

The entity which makes an initial reconsidered or revised determination may re-open the determination. 

Re-openings occur after a decision has been made.  Re-openings may be granted:

-   To correct an error
-   In response to suspected fraud
-  In response to the receipt of information not available or known to exist at the time the claim were initially processed

A re-opening is not an appeal right. A party may request a reopening even if it still has appeal rights, as long  as  the  guidelines  of  the  re-opening  are  met.    For  example,  if  a  member  receives  an  adverse determination, but later obtains relevant medical records, he or she may request a re-opening rather than a hearing  before  an  ALJ.    However,  if  the  beneficiary  did  not  have  additional  information  and  just disagreed with the reasoning of the decision, he or she must file an appeal.  If a member requests a re-opening  while  he  or  she  still  has  appeal  rights,  he  or  she  will  also  file  for  the  appeal  and  ask  for  a continuance until the re-opening is decided.  If the re-opening is denied or the original determination is not revised, the party retains its appeal rights.

The  party  that  filed  the  reconsideration  may  withdraw  that  request.    The  withdrawal  must  be  filed  in writing  to  the  Plan,  the  Social  Security  Office  or  the  Railroad  Retirement  Board  office  (for  railroad retirees).  The withdrawal will be acknowledged in writing by the Plan.

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