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.
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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