CMS Finalizes Rule to Streamline Medicare Appeals Process

May 2019 ~

CMS has issued a final rule clarifies changes it has made to the appeals process in the Medicare program for providers, beneficiaries, and suppliers, and streamlines the process for Medicare Parts A and B claims appeals and for Medicare Part D coverage determination appeals.

According to CMS, the changes made under the Medicare Program; Changes to the Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedures rule have been designed to reduce the administrative burden on providers, suppliers, beneficiaries, and appeal adjudicators. The Final Rule revises regulations setting forth the appeals process that Medicare beneficiaries, providers, and suppliers must follow to appeal adverse determinations regarding claims for benefits under Medicare Parts A and B, or determinations for prescription drug coverage under Part D.

“These revisions, which include technical corrections, also help to ensure the regulations are clearly arranged and written to give stakeholders a better understanding of the appeals process,” the agency said.

Significant changes to be implemented under the rule can be seen below.

  • Removal of Requirement that Appellants Sign Appeal Requests
    • “In order to promote consistency between appeal levels, ensure transparency in developing our appeal request requirements, help ensure that we do not impose nonessential requirements on appellants, reduce the burden on appellants, and improve the appeals process based on our experience, we proposed that appellants in Medicare Parts A and B claim and Part D coverage determination appeals be allowed to submit appeal requests without a signature. Specifically, we proposed to revise §§ 405.944(b)(4), 405.964(b)(4), 405.1112(a), and 423.2112(a)(4) to remove the requirement of the appellant’s signature for appeal requests (83 FR 49525 through 49529).”
  • Change to Timeframe for Vacating Dismissals
    • “To provide more consistency and predictability for appellants and adjudicators, and better conformity with other timeframes in part 405, subpart I, and part 423, subpart U, we proposed (83 FR 49525 through 49529) to revise the timeframe for vacating a dismissal from 6 months to 180 days in §§ 405.952(d), 405.972(d), 405.1052(e), and 423.2052(e).”
  • Technical Correction to Regulations to Change Health Insurance Claim Number (HICN) References to Medicare Numbers
    • “we proposed (83 FR 49527 through 49529) to revise the following provisions of Medicare regulations to remove the words “health insurance claim” from the phrase “Medicare health insurance claim number” so that there is only a reference to “Medicare number”: §§ 405.910(c)(5), 405.944(b)(2), 405.964(b)(2), 405.1014(a)(1)(i), 405.1112(a), 423.2014(a)(1)(i), and 423.2112(a)(4).”
  • Removal of Redundant Regulatory Provisions Relating to Medicare Appeals of Payment and Coverage Determinations
    • “we proposed to remove § 423.1970 (83 FR 49527). We stated that because § 423.1970(a) is redundant of §§ 423.2000(a) and 423.2002(a)(2) in describing that an enrollee has a right to an ALJ hearing when the enrollee is dissatisfied with an IRE reconsideration and meets the AIC requirement, we believe § 423.1970(a) should be eliminated. We proposed to relocate § 423.1970(b) and (c) to new proposed § 423.2006 (“Amount in controversy required for an ALJ hearing and judicial review”) as paragraphs (c) and (d), respectively (83 FR 49527 and 49528).”
    • “In addition, we proposed to remove the reference to “CMS” in § 423.1970(b) (relocated to proposed § 423.2006(c)) to clarify that adjudicators, not CMS, ultimately compute the amount remaining in controversy in determining whether the AIC threshold is met for an ALJ hearing or review of an IRE dismissal, and judicial review (83 FR 49528).”
  • Change to Timeframe for Referral to Medicare Appeals Council
    • “To provide more consistency and predictability for appellants and adjudicators, and better conformity with other timeframes in part 405, subpart I, and part 423, subpart U, we proposed (83 FR 49525 through 49529) to revise the timeframe for vacating a dismissal from 6 months to 180 days in §§ 405.952(d), 405.972(d), 405.1052(e), and 423.2052(e).”
  • Technical Correction to Regulation Regarding Duration of Appointed Representative in a Medicare Secondary Payer Recovery Claim
    • “We proposed to revise § 405.910(e)(4) to correct the cross-reference (83 FR 49525). We stated in the proposed rule that this proposed correction would not alter any existing processes or procedures within the Medicare claims appeals process.”
  • Technical Correction to Actions that are Not Initial Determinations
    • “we proposed to revise § 405.926(f) to remove the incorrect reference to “§ 483.5(n)” and replace it with the cross-reference “§ 483.5 definition of `transfer and discharge’ ” (83 FR 49525). We stated Start Printed Page 19861that this proposed technical correction would serve to correct an incorrect citation. We further explained that it would not alter any existing processes or procedures within the Medicare claims appeals process (83 FR 49518).”
  • Changes to Enhance Implementation of Rule Streamlining the Medicare Appeals Procedures
    • “Since we published on January 17, 2017, the final rule, we have identified several provisions that, upon further review, pose unanticipated challenges with implementation, which are explained in this section. In addition, there are other regulatory provisions that we believe require additional clarification and the correction of technical errors and omissions. In the proposals listed in this section, we sought to help ensure the provisions are implemented as intended, provide clarification, and correct technical errors and omissions. Our proposed changes were as follows.”
  • Amount in Controversy
    • “To account for situations where the amount of an overpayment specified in the demand letter does not reflect subsequent adjustments to the amount remaining in controversy, we proposed to revise § 405.1006(d)(4) to state that when an appeal involves an identified overpayment, the AIC is the amount of the overpayment specified in the demand letter, or the amount of the revised overpayment if the amount originally demanded changes as a result of a subsequent determination or appeal, for the items or services in the disputed claim (83 FR 49525). For appeals involving an estimated overpayment amount determined through the use of statistical sampling and extrapolation, we further proposed to revise § 405.1006(d)(4) to state that the AIC is the total amount of the estimated overpayment determined through extrapolation, as specified in the demand letter, or as subsequently revised (83 FR 49525).”

The rule also incorporates regulatory changes concerning notices of hearings, notices of intent to participate in hearings, extensions of time to request hearings, dismissals of hearing requests, and notices of remand.

The “Medicare Program; Changes to the Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedures (84 FR 19855),” was published in the Federal Register on May 7 and will take effect on July 8.

 

 

Source(s): Federal Register; Lexology; Provider Magazine; JD Supra;

 

 

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