Rev. January 2020
MAXIMUS Federal
Medicare
Health Plan
Reconsideration
Process Manual
Medicare Managed Care
Reconsideration Project
MAXIMUS Federal
3750 Monroe Ave. Ste. 702
Pittsford, New York 14534-1302
(585) 348-3300
Rev. January 2020
1
MAXIMUS FEDERAL CONTACT INFORMATION
Address:
MAXIMUS Federal
Medicare Managed Care Reconsideration Project
3750 Monroe Ave. Ste. 702
Pittsford, New York 14534-1302
Telephone:
Main Number: 585-348-3300
Key Contacts:
Katy Hanson, MAXIMUS Federal, Project Director,
Medicare Managed Care Reconsideration Project
Assistant to Project Director/Part C Plan Liaison,
MAXIMUS Federal, Medicare Managed Care
Reconsideration Project
Email: medica[email protected]
Patrick Pinnell, MAXIMUS Federal, QIC Program Director
Please use this email address for all questions: medicareappeal@maximus.com
Case Status Inquiries:
Web site: www.medicareappeal.com
Email: medicareappeal@maximus.com
Customer Service: 585-348-3300
Fax:
Case Information Fax: 585-425-5292
(Please submit only case-specific information, such as responses to Requests for
Information – do not submit confidential case specific information by email)
Project Web Site:
www.medicareappeal.com
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Table of Contents
Section Page
1. INTRODUCTION 6
2. DEFINITIONS 7-10
2.1. Adjudicator 7
2.2. Appeal 7
2.3. Appeal Process 7
2.4. Authorized Representative 7
2.5. De Novo Review 7
2.6. Enrollee 7
2.7. Evidence of Coverage 8
2.8. Expedited Reconsideration 8
2.9. Independent Review Entity (IRE) 8
2.10 Local Coverage Decision (LCD) 8
2.11 Medicare Advantage Organization 8
2.12 Medicare Appeal System (MAS) 9
2.13 Medicare Health Plan 9
2.14 Organization Determination 9
2.15 Reconsideration 9
2.16 Reconsideration Determination Notice 9
2.17 Reopening 9
2.18 Request for Information (RI) 10
2.19 Standard Claim Reconsideration 10
2.20 Standard Service Reconsideration 10
2.21 Standard Service Part B Drug Reconsideration (Effective 1/1/2020) 10
3. WORKING WITH MAXIMUS FEDERAL 11-15
3.1. Sources of Information about MAXIMUS Federal IRE Reconsideration 11-13
3.2. Set-Up of New Managed Care Organization with MAXIMUS Federal 13
3.3. Identifying and Changing Medicare Health Plan Point of Contact 13
3.4. Seeking Information about Cases 14
3.5. Suggestions and Complaints 14
3.6. Holidays 15
4. BACKGROUND – IMPORTANT CONSIDERATIONS PRIOR TO DEVELOPING THE
RECONSIDERATION CASE FILE FOR SUBMISSION TO MAXIMUS FEDERAL 16-24
4.1. Medicare Health Plan’s Organization Determination Notice Requirements 16-18
4.2. Medicare Health Plan Validation of Party, Representative, and Eligible Appeal 18-22
4.3. Non-Medicare Plan Services 22
4.4. Reconsideration Priority 23
4.5. Medicare Health Plan Responsibility to Conduct a Full Reconsideration 23
4.6. Medicare Health Plan Reconsideration with incomplete Evidence 24
5. SUBMITTING VALID RECONSIDERATION CASE FILES TO MAXIMUS FEDERAL 25-34
5.1. Cases that Must be Submitted to MAXIMUS Federal for Reconsideration 25
5.2. Time Standards for Submission of Cases to MAXIMUS Federal 25-29
5.3. Preparation and Submission of the New Case File to MAXIMUS Federal 29-34
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6. MAXIMUS FEDERAL RECONSIDERATION PROCESS 35-41
6.1. MAXIMUS Federal Case Processing Time Standards 35
6.2. Administrative Case Intake 36
6.3. Policies on Communication with Medicare Health Plan and Appellant During
Case Processing 36-37
6.4. Adjudicator Case Review 37
6.5. Physician Review 37-38
6.6. Requests to Medicare Health Plan for Additional Information 38-40
6.7. Reconsideration Determination Notices 40-41
6.8. Enrollee Requests for Case File 41
7. POST-RECONSIDERATION DETERMINATION PROCESSING 42-47
7.1. MAXIMUS Federal Monitoring of Medicare Health Plan Compliance with
Overturned Determinations 42-43
7.2. IRE Reopening Process 44-45
7.3. Office of Medicare Hearings and Appeals Process 45-46
7.4. Medicare Appeals Council Process 46-47
8. HEALTH PLAN DISMISSAL PROCESSING AND APPEALS 48-51
8.1. Notice of Dismissal of Appeal Request 48
8.2. Dismissal Case File Requests 48-49
8.3. MAXIMUS Federal Review of Dismissal Decision 49
8.4. Dismissal Case File Documentation 50
8.5. Timeframes for MAXIMUS Federal Review 50-51
8.6. Dismissal Review Decisions are Binding 51
9. RECONSIDERATION DATA 52-56
9.1. Medicare Appeals System 52
9.2. Medicare Health Plan Monitoring Reports 52-54
9.3. Using the MAXIMUS Federal Website to Track Timeliness and Effectuation 54-56
LIST OF EXHIBITS
Exhibit Title Page
3-1 Medicare Managed Care & Pace Reconsideration Project Website 12
5-1 Expedited Case Submission Timetable 27
5-2 Explanation of “Case Material” 31
5-3 Suggested Medical Records for Inpatient and Long-Term Care Denials 33
5-4 Suggested Medical Records for Other Common Types of Denials 33
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APPENDIX
The following Reconsideration Case Forms and Instructions are contained in the separate
Appendix to this Reconsideration Process Manual:
Instructions for Reconsideration Background Data Form (RBDF) and Case Narrative
Reconsideration Background Data Form
Instructions for Dismissal Case File Data Form (DCFDF)
Dismissal Case File Data Form
New Reconsideration Case Transmittal Cover Sheet
Request for Information Response Cover Sheet
Statement of Compliance Form
Reopening Request Form
Statement of Compliance Form- ALJ
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MAXIMUS Federal
MEDICARE HEALTH PLAN
RECONSIDERATION PROCESS MANUAL
MEDICARE MANAGED CARE RECONSIDERATION PROJECT
Effective October 2019
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1. INTRODUCTION
The Balanced Budget Act of 1997, as amended by Title II of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA), requires the federal government to contract
with an Independent Review Entity (IRE) to review and resolve coverage disputes between Medicare
Advantage Organizations, Cost Plans and HCPPs (collectively referred to as Medicare Health Plans),
and Medicare managed care enrollees. The Centers for Medicare & Medicaid Services (CMS) has
contracted with MAXIMUS Federal to serve as this independent entity.
This manual contains the procedures for the coordination of Medicare Health Plans with
MAXIMUS Federal in the processing of IRE level reconsiderations, and related post- reconsideration
activities.
The IRE level reconsideration is one step in a larger multi-level Medicare Managed Care
appeal process. For example, Medicare Health Plans are required to adhere to CMS policies for initial
organization determinations and Medicare Health Plan level reconsiderations—steps that occur well
prior to the submission of a case file to MAXIMUS Federal. The focus of this manual is on the
processes by which Medicare Health Plans and MAXIMUS Federal interrelate for the IRE level
reconsideration. This manual is not intended to serve as a review of CMS policy governing Medicare
Health Plan obligations for the appeal process overall. This manual presumes that the reader has a
command of relevant Medicare policies such as:
· 42 CFR §422
· Medicare Managed Care Manual
· Program Memoranda and Transmittals
Certain policies, procedures, and operational documents discussed in this manual are
mandatory, and complete compliance by the Medicare Health Plan is expected. For such
requirements, the term "must" or "mandatory" is used. In other areas we have attempted to provide
the Medicare Health Plan with flexibility, but may have offered suggestions for work methods that
we believe will enhance the working relationship between Medicare Health Plans and MAXIMUS
Federal. In these areas, the term "recommended" or "suggested" or "optional" is used.
Our hope is that the Medicare Health Plan user finds this manual clear and helpful. If you
have suggestions or comments, please submit to:
Katy Hanson, Project Director
Medicare Managed Care Reconsideration Project MAXIMUS Federal
3750 Monroe Avenue Ste. 702
Pittsford, New York 14534-1302
Phone: 585-348-3300
Fax: 585-425-5292
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2. DEFINITIONS
The following definitions are provided solely for use in this Manual. These definitions do not
address all the significant terms used in 42 CFR §422, and in some instances paraphrase or
summarize regulatory text. In the event of any discrepancy or inconsistency, the language of 42 CFR
§422 supersedes these definitions.
2.1 ADJUDICATOR
An appeal professional employed by MAXIMUS Federal to manage individual
reconsideration case files. MAXIMUS Federal Adjudicators make coverage determinations.
Adjudicators do not make medical necessity determinations. Medical necessity determinations are
made by fully credentialed board- certified physicians under contract with MAXIMUS Federal.
2.2 APPEAL
A procedure to review a Medicare Health Plan's adverse organization determination that is
contested by the enrollee or another authorized party. The term appeal applies to such procedures at
any level of the multi-step Medicare Managed Care appeal process (for example, Medicare Health
Plan reconsideration, IRE level reconsideration, ALJ hearing, and so on).
2.3 APPEAL PROCESS
The entire multi-level Medicare managed care complaint process for addressing enrollee
challenges to a Medicare managed care adverse organization determination. The IRE reconsideration
process is one level in the broader Medicare managed care appeal process.
2.4 AUTHORIZED REPRESENTATIVE
An individual appointed by an enrollee to represent him/her in filing an appeal. See Section
4.2.1 for additional information. Also known as Appointed Representative.
2.5 DE NOVO REVIEW
A review of an individual dispute by a new and impartial reviewer. The new and impartial
reviewer does not give preference to any previous determinations made on the individual dispute.
2.6 ENROLLEE
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A Medicare beneficiary who has enrolled in a Medicare Health Plan. An enrollee may also be
known as a member.
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2.7 EVIDENCE OF COVERAGE
This term describes the Medicare Health Plan document that sets forth the terms of coverage
for the Medicare Health Plan enrollees. This document is sometimes called a Subscriber Contract or
Subscriber Agreement.
2.8 EXPEDITED RECONSIDERATION
A de novo review of an adverse organization determination that must be processed quickly to
avoid endangering the life or health of the enrollee or the enrollee's ability to regain or maintain
maximum function. Generally, expedited reconsiderations must be completed as soon as is medically
indicated, but not longer than 72 hours, with a possible extension of up to 14 calendar days if the
delay is in the enrollee's interest (See 42 CFR §422.590). Examples of cases that should be expedited
include pre-service skilled nursing facility cases, pre-service acute inpatient care cases and cases in
which a physician indicates that applying the standard timeframe for making a determination could
seriously affect the life or health of the enrollee or the enrollee's ability to regain maximum function.
The Medicare Health Plan has an obligation to determine if an appeal should be expedited,
including responding to an enrollee or provider request for expedited determination. However,
MAXIMUS Federal has the authority to expedite processing of an IRE reconsideration that was not
expedited by the Medicare Health Plan.
2.9 INDEPENDENT REVIEW ENTITY (IRE)
The entity under contract with CMS to perform reconsideration of denials upheld at the
Medicare Health Plan level reconsideration. MAXIMUS Federal is the Independent Review Entity.
2.10 LOCAL COVERAGE DECISION (LCD)
A document, identified as an LCD, published by a Medicare fee for service contractor with
jurisdiction over fee for service claims in a defined area that specifies coverage or clinical criteria for
fee for service claim reimbursement.
2.11 MEDICARE ADVANTAGE ORGANIZATION
An entity that is under contract with CMS to provide Medicare benefits to Medicare
beneficiaries. Medicare Advantage Organizations offer Medicare Advantage Plans such as HMOs,
PSOs, PPOs, SNPs MSAs and private FFS plans and certain other programs and demonstration
projects. The determination of whether an entity is subject to the Medicare Advantage appeals
requirements is made by CMS, not MAXIMUS Federal.
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2.12 MEDICARE APPEAL SYSTEM (MAS)
Data system used by MAXIMUS Federal for collecting specific data elements from
reconsideration cases and for creating specific reports for CMS.
2.13 MEDICARE HEALTH PLAN
Term used in this Manual and in MAXIMUS Federal correspondence to refer to a Medicare
Advantage Plan, Cost Plan, and/or HCPP.
2.14 ORGANIZATION DETERMINATION
A decision of the Medicare Health Plan, or a person acting on its behalf, to approve or deny a
payment for a health care service or a request for provision of health care service made by, or on
behalf of, a Medicare Health Plan enrollee. An organization determination concerns benefits an
enrollee is entitled to receive under the Medicare Health Plan, including basic benefits; mandatory
and optional supplemental benefits; and cost-sharing (deductible, coinsurance, and/or copayment).
An organization determination is the Medicare Health Plan's initial coverage determination. Medicare
Health Plans must have procedures for making standard determinations and expedited
determinations. Expedited determinations apply to cases in which applying standard determination
procedures could seriously jeopardize the enrollee's life, health or ability to regain maximum function
(See 42 CFR §§422.566-422.572).
2.15 RECONSIDERATION
A review of an adverse organization determination. This term applies both to the Medicare
Health Plan and IRE level appeal proceeding.
2.16 RECONSIDERATION DETERMINATION NOTICE
Letter used to communicate MAXIMUS Federal final decision in a reconsideration.
2.17 REOPENING
A review of a completed IRE reconsideration determination undertaken at the sole discretion
of the IRE for the purpose of addressing new information received or a potential error in the
determination (See42 CFR §422.616).
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2.18 REQUEST FOR INFORMATION (RI)
A MAXIMUS Federal document submitted to the Medicare Health Plan requesting
information from the Medicare Health Plan to correct a case file deficiency.
2.19 STANDARD CLAIM RECONSIDERATION
Reconsiderations related solely to a denial of claim payment or reimbursement. Claim
reconsiderations must be completed within 60 days of request receipt. Claim reconsiderations may
not be expedited. May also be referred to as a retrospective appeal.
2.20 STANDARD SERVICE RECONSIDERATION
Reconsiderations of denials of authorization for items or services, including continuing
services, which do not meet the criteria for an expedited reconsideration. Standard service
reconsiderations must be completed within 30 calendar days of the request receipt, subject to a
possible 14-calendar day extension if in the enrollee's interest. May also be referred to as a pre-
service appeal.
2.21 STANDARD SERVICE PART B DRUG RECONSIDERATION (Effective 1/1/2020)
Reconsideration of denials of authorization for Medicare Part B coverable drugs, including
continuation of usage of a Part B drug, which do not meet criteria for an expedited reconsideration.
Standard Service Part B Drug Reconsiderations must be completed within 7 calendar days of the
request receipt. These requests are not subject to any extensions and may also be referred to as pre-
service Part B drug appeals.
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3. WORKING WITH MAXIMUS FEDERAL
This Chapter explains the basic processes for communicating with MAXIMUS Federal,
under the following headings:
3.1 Sources of Information about MAXIMUS Federal IRE Reconsideration
3.2 Set-up of New Managed Care Organizations with MAXIMUS Federal
3.3 Identifying and Changing Medicare Health Plan Points of Contact with MAXIMUS
Federal
3.4 Seeking Information about Active Cases
3.5 Suggestions and Complaints
3.6 Holidays
Please note that MAXIMUS Federal is not authorized by CMS to guide or instruct
Medicare Health Plans on interpretation of CMS coverage policies, or matters related to
Medicare Health Plan compliance with CMS appeals process requirements. For example, we
are not able to offer Medicare Health Plans advice on how a hypothetical case would be decided if
presented to us. Policy inquiries of this type should be directed by the Medicare Health Plan to its
designated CMS Regional Office Account Manager.
3.1 SOURCES OF INFORMATION ABOUT MAXIMUS FEDERAL IRE
RECONSIDERATION
Medicare Managed Care and PACE Reconsideration Project Process Manuals
MAXIMUS Federal makes available process manuals for the Medicare Managed Care and
PACE Reconsideration Project as the primary print source for information about the IRE program.
MAXIMUS Federal makes available on its web site two manuals: one manual for Medicare
Advantage plans and one manual for PACE Organizations. Each Manual contains process
information specific to the Health Plan type. Medicare Health Plans are welcome to download the
applicable manual from the Project web site, www.medicareappeal.com.
Medicare Managed Care & PACE Reconsideration Project Web Site
In addition to the process manuals, the Project web site, www.medicareappeal.com (See
Exhibit 3-1) contains the following information:
· Links to CMS web sites for statute, regulation and manuals related to Medicare Managed
Care Reconsideration
· Project newsletter, Recon Notes
· Updated Project organization and contact information
· National, Regional and Medicare Health Plan level Reconsideration data
· Case Status Information
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Exhibit 3-1
Medicare Managed Care & PACE Reconsideration Project Web Site
Case status information on the Project web site is purposefully limited to protect enrollee and
Medicare Health Plan confidentiality. The case can only be accessed by the "reconsideration case
number" that is assigned by the Medicare Appeal System upon receipt of a case file from the
Medicare Health Plan. A reconsideration case number has no logical relationship to Social Security
Number, Medicare Number, or any other confidential information. The information that can be
obtained by reconsideration case number is limited to:
· IRE Request received date
· IRE Appeal Priority (Expedited, Standard Service, Standard Service Part B Drug, Standard
Claim)
· Plan Reported Recon Receipt Date (from the Reconsideration Background Data Form)
· IRE Corrected Recon Receipt Date (if different than the Plan Reported Recon Receipt Date)
· Plan Extension
· IRE Recon Decision (Unfavorable, Favorable, Partially Favorable, Withdrawn, Dismissed, or
Pending)
· IRE Reopen Decision (if applicable)
· ALJ Decision (if applicable)
· Last Decision Date
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Project Newsletter ("Recon Notes")
When directed to do so by CMS, MAXIMUS Federal publishes a newsletter, "Recon Notes,"
which addresses commonly observed situations in the reconsideration process and updates
MAXIMUS Federal policies and procedures as needed. This newsletter is available to Medicare
Health Plans and the public through our web site: www.medicareappeal.com.
3.2 SET-UP OF NEW MANAGED CARE ORGANIZATIONS WITH MAXIMUS
FEDERAL
An entity that has established a new Medicare Advantage contract with CMS is encouraged to
contact MAXIMUS Federal prior to its first enrollment effective date. Email or write to MAXIMUS
Federal at medicareappeal@maximus.com. MAXIMUS Federal will arrange to provide the new
Medicare Health Plan a telephonic briefing on the IRE project.
3.3 IDENTIFYING AND CHANGING MEDICARE HEALTH PLAN POINT OF
CONTACT
3.3.1 MEDICARE HEALTH PLAN KEY ORGANIZATION CONTACT
As part of new Medicare Health Plan project set-up, MAXIMUS Federal requests that each
Medicare Health Plan designate and maintain one key organization contact. Medicare Health Plans
that operate under multiple CMS contract numbers must designate and maintain a Key Contact for
each CMS contract. The Medicare Health Plan may use the same, or different, personnel as the Key
Contact for each contract. This individual will be the official management contact with MAXIMUS
Federal. MAXIMUS Federal will send the Key Contact all important materials. We will also contact
this individual if we encounter a general issue working with the Medicare Health Plan, or an unusual
and significant case-specific problem. The Medicare Health Plan should use the Key Contact to initiate
contact with MAXIMUS Federal to resolve problems perceived by the Medicare Health Plan. To
identify or change this individual, submit the Notice of Change in Key Organization Contact (located
in Appendix) to MAXIMUS Federal via our project email box at medicareappeal@maximus.com.
3.3.2 MEDICARE HEALTH PLAN INDIVIDUAL RECONSIDERATION CASE
CONTACTS
The Medicare Health Plan must designate a contact person on a Reconsideration Background
Data Form submitted with each reconsideration case (See Appendix). The Medicare Health Plan may,
but is not required to, use its Key Contact as the designated case specific contact. The Medicare Health
Plan may vary the Case Contact from case to case.
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3.4 SEEKING INFORMATION ABOUT CASES
As discussed above, the Medicare Health Plan can obtain basic information concerning the
status of active and decided cases via the Project web site, www.medicareappeal.com.
In addition, you may call us at 585-348-3300. MAXIMUS Federal maintains a staffed
switchboard Monday to Friday from 8 AM to 5:30 PM and Saturday from 9 AM to 2 PM, Eastern
Time. For calls made after normal business hours, you may choose to leave a message that will be
returned the next business day or you may contact us via email at medicareappeal@maximus.com.
For inquiries simply about the processing status of a specific case file, or group of cases, please
visit our website www.medicareappeal.com.
MAXIMUS Federal employs a staff of Adjudicators who manage individual reconsideration
case files. Specific questions about a case under review may be directed to
[email protected]. Information that is to be made part of the case file and used in the
final determination must be submitted in writing.
Medicare Health Plans are responsible for supporting their enrollees in the reconsideration
process. Plans should not direct members to MAXIMUS Federal for routine case status inquiries.
Medicare managed care enrollees may be referred to 1-800-MEDICARE for general
information regarding the Medicare managed care appeals process and to locate resources for
assistance in the appeals process.
3.5 SUGGESTIONS AND COMPLAINTS
MAXIMUS Federal is an ISO 9001:2008 certified Independent Review Entity. As such,
management requires a formal process for identification of opportunities for corrective and preventive
action, or continuous improvement. Please freely provide any suggestions or complaints to any
MAXIMUS Federal staff member who is interacting with you, or to the Project Director. If you are not
completely satisfied, the MAXIMUS Federal QIC Program Manager would appreciate the opportunity
to address your concern.
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3.6 HOLIDAYS
MAXIMUS Federal offices will be closed in observance of the following Federal holidays:
· New Year’s Day
· Martin Luther King, Jr. Day
· Presidents’ Day
· Memorial Day
· Independence Day
· Labor Day
· Columbus Day
· Veterans Day
· Thanksgiving Day
· Christmas Day
MAXIMUS Federal will accept delivery of case files on those days through the QIC Appeals
Portal or secure file transfer with the following business day being used as the date of receipt. If you
intend to submit a case for receipt by MAXIMUS Federal on one of the above-listed days, you must
contact MAXIMUS Federal via telephone (585-348-3300) at least 24 hours in advance to arrange for
that case file delivery.
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4. BACKGROUND - IMPORTANT CONSIDERATIONS PRIOR TO
DEVELOPING THE RECONSIDERATION CASE FILE FOR SUBMISSION
TO MAXIMUS FEDERAL
The responsibilities of the Medicare Health Plan related to adverse organization determination
("denials") and the Medicare Health Plan level reconsideration are defined by CMS in 42 CFR §422,
Subpart M, and Chapter 13 of the CMS Medicare Managed Care Manual. This MAXIMUS Federal
Medicare Health Plan Reconsideration Process Manual is based on the presumption that the Medicare
Health Plan understands and complies with these CMS policies, and is not an instruction guide for
them.
The purpose of this Chapter is to highlight certain aspects of Medicare Health Plan’s
organization determination and reconsideration processing that directly impact subsequent IRE
reconsideration. The topics addressed are:
4.1 Medicare Health Plan’s Organization Determination Notice Requirements
4.2 Medicare Health Plan Validation of Party, Representative, and Eligible Appeal
4.3 Non-Medicare Plan Services
4.4 Reconsideration Priority
4.5 Medicare Health Plan Responsibility to Conduct a Full Medicare Health Plan
Reconsideration
4.6 Medicare Health Plan Reconsideration with Incomplete Evidence
4.1 MEDICARE HEALTH PLAN’S ORGANIZATION DETERMINATION NOTICE
REQUIREMENTS
The Medicare Health Plan is required, in most instances, to provide a written organization
determination ("denial") notice to the enrollee or the enrollee's representative (See Section 4.2). If a
denial is subsequently appealed to MAXIMUS Federal for reconsideration, a copy of the denial notice
and dates pertaining to Medicare Health Plan organization determination processing must be included
within the case file.
MAXIMUS Federal closely reviews the organization determination to define the denied
service or claim subject to IRE reconsideration. In addition, we compare the type, format, and content
of the notice to CMS requirements and report "notice deficiencies" to CMS. Finally, MAXIMUS
Federal abstracts and reports to CMS the dates of the initial request for service (or payment) versus
organization determination, for purposes of monitoring Medicare Health Plan timeliness. The
organization determination date is the date on which a decision was communicated to the enrollee or
appellant, whether orally or in the form of a decision letter.
CMS has developed standardized denial notices, which are described in the subsections
following.
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4.1.1 NOTICE OF DENIAL OF MEDICAL COVERAGE (NDMC)
This OMB-approved notice applies to prior authorization denials, adverse organization
determinations including termination of medical services (excepting Inpatient discharge denials). The
Medicare Health Plan must issue an NDMC when it receives a request for a service and the Medicare
Health Plan denies the request, in whole or part. However, CMS policy recognizes that some "denials"
may occur in the context of provider discussions with enrollees about patient care options, and that in
such discussions it may be difficult to ascertain whether or not the enrollee believes a denial has
occurred at that instant. For example, if an enrollee is discussing two treatment options with a
physician, the physician might recommend the second option. Whether such a recommendation is a
"denial" of the first option depends upon the enrollee's response (that is, acceptance or rejection of the
physician's recommendation). Further, the enrollee might not contest the physician's recommendation
during the visit, but could contest it at a later date.
Due to these unavoidable complications, CMS policy does not obligate Medicare Health Plan
providers to issue an NDMC, but does obligate providers to inform enrollees of their right to obtain an
NDMC from the Medicare Health Plan. The Medicare Health Plan must issue the NDMC if so
requested by the enrollee. If the Medicare Health Plan makes the denial (for example, in response to a
provider's request for prior authorization), the Medicare Health Plan must issue the NDMC.
In summary, in many instances the circumstances of an initial organization determination will
necessitate issuance of an NDMC by the Medicare Health Plan. If so, the NDMC must be included in
a case file submitted for IRE reconsideration. If a valid exception to the NDMC issuance requirement
exists, the Medicare Health Plan should document the exception in the IRE case file.
CMS has issued a standard form for the NDMC. Medicare Health Plans may not deviate from
the language of the CMS form. Please note that the OMB control number must be displayed on the
notice. A copy of the completed NDMC must be included in the Medicare Health Plan reconsideration
case file.
4.1.2 NOTICE OF DENIAL OF PAYMENT (NDP)
A Medicare Health Plan completes and issues this notice when it denies a request for payment
of a service that was already received by the enrollee. While CMS does have an OMB- approved
notice, CMS also permits Medicare Health Plans to use the Medicare Health Plan's existing electronic
formats that generate Explanation of Benefits forms, as long as the back or a separate attachment
contains the NDP information about appeal rights.
A copy of the completed NDP must be included in the Medicare Health Plan reconsideration
case file.
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4.1.3 NOTICE OF MEDICARE NON-COVERAGE (NOMNC)
This OMB-approved notice should be issued when the Medicare Health Plan discontinues
coverage for Skilled Nursing Facility (SNF) stays, Home Health services, or CORF services. CMS has
specific requirements with regard to time and manner of delivery of this notice (See 42 CFR §422.624
and CMS Medicare Managed Care Manual, Chapter 13).
Telephone delivery of the notice is permitted only in limited circumstances, and there are
specific requirements with regard to the documentation of the telephone call (See CMS Medicare
Managed Care Manual, Chapter 13 for full details). A copy of the completed NOMNC must be
included in the Medicare Health Plan reconsideration case file.
It is important to note that reduction of a service within the SNF, Home Health, or CORF
setting that does not result in termination of skilled coverage does not require the use of the NOMNC.
Medicare Health Plans should use the NDMC for this purpose. Also, please note that CMS does not
require use of the NOMNC in denials based on exhaustion of benefits. For terminations based on the
exhaustion of Medicare benefits, Medicare Health Plans should use the NDMC.
4.2 MEDICARE HEALTH PLAN VALIDATION OF PARTY, REPRESENTATIVE AND
ELIGIBLE APPEAL
Federal regulations provide that the following parties may request a reconsideration of an
organization determination:
· An enrollee (including his or her representative)
· An assignee of the enrollee (that is, a non-contract physician or other non-contract provider
who has furnished a service to the enrollee and formally agrees to waive any right to payment
from the enrollee for that service)
· The legal representative of a deceased enrollee's estate
· Any other provider or entity (other than the Medicare Health Plan) determined to have an
appealable interest in the proceeding (See 42 CFR §§422.574 and 422.578)
It is a straightforward validation of the appealing party when the enrollee initiates the
reconsideration request. It is not as straightforward to validate the appealing party when the
Reconsideration request is made by a person other than the enrollee. Special considerations with
respect to reconsideration requests made by persons other than the enrollee are discussed under the
following sub-headings:
4.2.1 Representative Documentation
4.2.2 Provider-as-Party Documentation
4.2.3 Provider as Person "Supporting" the Enrollee Appeal
4.2.4 Representative of a Deceased Enrollee’s Estate
4.2.5 Processing Reconsiderations with an Invalid Appeal Requestor
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Medicare Health Plans should carefully note that until an authorized representative or
provider-as-party is formally validated and documented, the appeal process, including the Medicare
Health Plan reconsideration, should not begin. In other words, if the Medicare Health Plan receives an
appeal request from a representative who is not validated (See Section 4.2.1), the Medicare Health Plan
should not initiate the Medicare Health Plan reconsideration process. The procedures in Section 4.2.5
instruct the Medicare Health Plan on proper technique for addressing Medicare Health Plan
reconsideration requests submitted by non-validated representatives or providers-as-party.
4.2.1 REPRESENTATIVE DOCUMENTATION
It is the responsibility of the Medicare Health Plan, not MAXIMUS Federal, to correctly
identify and apply the laws and procedures related to representation.
An enrollee may designate any person as his or her representative. CMS in general requires
that Medicare Health Plans document proof of the validity of the enrollee's representative. Special
rules apply to two circumstances:
1. Enrollees who are incapacitated
2. Providers as representatives.
General Requirements
If the party requesting the reconsideration is not the enrollee, and the special circumstances
discussed below do not apply, it is the responsibility of the Medicare Health Plan to determine and
document that the requesting party is an appropriate representative of the enrollee (See CMS Medicare
Managed Care Manual, Chapter 13). Appropriate documentation may include, but is not limited to, a
durable power of attorney, a health care proxy, an appointment of guardianship, an Appointment of
Representative form (CMS-1696), or other legally recognized forms of appointment. In the event the
Medicare Health Plan does not have access to these documents, an Appointment of Representative
form accepted by MAXIMUS Federal for this purpose is included in the Appendix of the Medicare
Managed Care Manual Chapter 13. Representative documentation is required even if the
representative is an attorney, family member, or medical provider (See Special Condition 2, below).
Representative documentation must be included in the case file submitted to MAXIMUS Federal for
IRE Reconsideration.
It is also the Medicare Health Plan’s obligation to attempt to obtain the needed representative
documentation. Plans must make, and document, their attempts to obtain this documentation. If a
Medicare Health Plan does not receive the representative documentation at the end of the appeal
timeframe, PLUS EXTENSION, the Medicare Health Plan must dismiss the request and issue a Notice
of Dismissal of Appeal Request. Appellants have the right to request review of this dismissal. These
dismissal reviews are discussed in more detail in Section 8 below.
Please note, this means that Medicare Health Plans must allow the full timeframe, plus any
extensions allowable, for the requestor to submit the representative documentation. Plans should not
issue a Notice of Dismissal of Appeal Request until the full timeframe, plus extension (if applicable),
has expired (See the Medicare Managed Care Manual, Chapter 13, §10.4).
Rev. January 2020
21
Special Condition 1: Enrollee Who Is Incapacitated or Incompetent
If a member is incapacitated or incompetent and cannot sign an appointment of representative
document, the Medicare Health Plan must apply state laws regarding legal representation of
incapacitated or incompetent persons. If these laws require documentation, such documentation should
be obtained by the Medicare Health Plan. The Medicare Health Plan's appeal staff should consult with
the Medicare Health Plan's legal counsel to follow the applicable laws. MAXIMUS Federal does not
require documentation in the IRE case file to substantiate that the Medicare Health Plan has properly
applied State law. However, the Medicare Managed Care Reconsideration Background Data Form
and the QIC Appeals Portal do include a checkbox (under section 4) that must be selected in order for
MAXIMUS Federal to accept the representative as valid (See Appendix).
The Appointment of Representative form (CMS-1696) can be found in Chapter 13 of the
Medicare Managed Care Manual.
Special Condition 2: A Physician May Initiate Expedited or Standard Pre-Service Reconsiderations
without Appointment of Representation or Without Being the Provider-as- Party. To determine if a
requestor is a “physician” please refer to Social Security Act §1861(r).
Any physician may make a reconsideration request on behalf of an enrollee to the Medicare
Health Plan to initiate an expedited reconsideration. A treating physician may, upon providing notice
to the enrollee, make a request for a standard pre-service reconsideration on the enrollee’s behalf.
These physicians are not required to obtain an appointment of representative document from the
enrollee, nor are these physicians required to execute a waiver of enrollee liability. Consequently, no
appointment of representative form is required in a case file submitted to MAXIMUS Federal. The
Medicare Health Plan must, however, document the physician request in the case file. Please note,
however, that appeals requested by non-physician providers require an Appointment of
Representation.
Federal regulations state that a physician must notify the enrollee of the standard service appeal
request. For purposes of processing the appeal, it is the Medicare Health Plan’s responsibility to assess
whether the enrollee has received proper notice. If the Medicare Health Plan processes the appeal
request, MAXIMUS Federal accepts that the Medicare Health Plan has sufficient proof that the
enrollee was properly noticed.
Note that an appointment of representative requirement does apply to a provider who attempts
to represent an enrollee in a standard claim reconsideration case.
4.2.1.1 Dismissal for lack of Proper Documentation
If a reconsideration case file is submitted to MAXIMUS Federal that was initiated by a
representative, MAXIMUS Federal will examine the file for compliance with the appointment
requirements. MAXIMUS Federal will dismiss cases in which a required fully executed appointment of
representative form is absent (See Section 4.2.5).
Rev. January 2020
22
4.2.2 PROVIDER-AS-PARTY DOCUMENTATION
4.2.2.1 Non-Contract Providers
A non-contract provider may itself become the party to an appeal if that non-contract provider
has executed a Waiver of Liability form. The purpose of this form is to ensure that the enrollee will not
be held financially liable if the provider loses the appeal. The executed Waiver of Liability document
must be included in the case file submitted to MAXIMUS Federal (See Section 4.2.5).
Managed Care Manual Chapter 13, §60.1.1 states that Medicare Health Plans must make, and
document, their attempts to obtain the Waiver of Liability. If the Medicare Health Plan does not
receive the Waiver of Liability by the conclusion of the appeal timeframe, the Medicare Health Plan
must dismiss the request and issue a Notice of Dismissal of Appeal Request. Non- Contract provider
appellants have the right to request review of this dismissal. These dismissal reviews are discussed in
more detail in Section 8 below.
Please note that this means that Medicare Health Plans should not issue a Notice of Dismissal
of Appeal Request for lack of a Waiver of Liability until the appeal timeframe has concluded.
A model Waiver of Liability form can be found in Chapter 13 of the Medicare Managed Care
Manual.
4.2.2.2 Contract Providers
Contract or "in-plan" providers of the Medicare Health Plan do not have rights to act as the
party in an appeal. Payment disputes between a contract provider and the Medicare Health Plan, for
which the enrollee has no liability, should be resolved through a forum outside of the Medicare
managed care appeal process.
4.2.3 PROVIDER AS PERSON "SUPPORTING" THE ENROLLEE APPEAL
Any person, including a provider, may "support" the enrollee appeal by providing written or
oral testimony at the Medicare Health Plan level reconsideration or written testimony at the IRE level
reconsideration. There is no requirement for execution of an appointment of representative or waiver
of liability if the role of the person is simply providing testimony in support of an enrollee's appeal.
The distinction between representation and support includes any of the following elements:(1) the
person supporting the appeal has no standing to request the appeal proceeding, whereas the
representative does, (2) the person supporting the appeal does not receive mandatory notices otherwise
sent to the enrollee, whereas the representative does, (3) the person supporting the appeal cannot make
decisions (for example, withdrawing the appeal), whereas the representative may do so, (4) the person
supporting the appeal does not otherwise "manage" the enrollee's participation in the appeal, whereas
the representative may.
Rev. January 2020
23
A physician may also, without being a representative, support a request for an appeal to be
classified as an expedited reconsideration. The physician may make his/her statement of support in
either written or oral form. The effect of such a statement is to mandate expedited status for the appeal
if the physician's statement indicates that the application of a standard decision timeframe to the
reconsideration could seriously jeopardize the life or health of the enrollee or the enrollee's ability to
regain maximum function.
4.2.4 REPRESENTATIVE OF DECEASED ENROLLEE'S ESTATE
The Medicare Health Plan has the responsibility to ensure that such representatives are
legitimate. The Medicare Health Plan must indicate on the Reconsideration Background Data Form
(by selecting the appropriate checkbox in section 4) or in the QIC Appeals Portal if the appeal request
initiated by an estate representative is valid. MAXIMUS Federal cannot rule on whether estate
representation documentation is legitimate. The Medicare Health Plan should consult its legal advisor
for assistance in determining the appropriate estate representative.
4.2.5 PROCESSING RECONSIDERATIONS WITH AN INVALID APPEAL
REQUESTOR
If the Medicare Health Plan receives a reconsideration request without the required executed
representative or waiver of liability document (or in which the required document is incomplete or
erroneous), the Medicare Health Plan level reconsideration review should not begin. However, the
Medicare Health Plan must make reasonable attempts to inform the requestor of the inadequacy and
obtain the representative or waiver of liability documents (See Chapter 13 of the Medicare Managed
Care Manual). If the Medicare Health Plan does not get the appropriate documentation, then the
Medicare Health Plan must dismiss the request per Chapter 13 of the Managed Care Manual.
Appellants may request review of this dismissal under the process described in Section 8 of this
manual.
4.3 NON-MEDICARE PLAN SERVICES
The Medicare Managed Care appeal process applies only to basic and mandatory or optional
supplemental benefits (42 CFR §422.566). Some enrollees have additional benefits, outside the scope
of the CMS approved benefit plan, provided separately by their employer or union. Denial of these
benefits is not subject to Medicare reconsideration, and such cases should not be submitted to
MAXIMUS Federal. However, if any portion of the denial overlaps Medicare basic benefits or the
Medicare Health Plan mandatory or optional supplemental benefits, the case does qualify for Medicare
reconsideration. Likewise, if the enrollee (or non- contract provider party) argues that the denied
service should be covered under the Medicare benefits, as opposed to the employer provided benefits,
the case should be reviewed as a Medicare reconsideration.
Rev. January 2020
24
4.4 RECONSIDERATION PRIORITY
Effective January 1, 2020, there are four levels of reconsideration priority:
1. Standard service reconsideration;
2. Standard service Part B Drug request reconsideration;
3. Standard claim payment reconsideration; and
4. Expedited reconsideration.
These four levels are defined in Section 2. Definitions. Refer also to 42 CFR §422 Subpart M
for a complete definition and explanation of the differing requirements for these reconsiderations.
The classification of a reconsideration as either an expedited or standard reconsideration is the
responsibility of the Medicare Health Plan. The Medicare Health Plan should not ask MAXIMUS
Federal to determine whether a given request for expedited reconsideration should be granted.
However, MAXIMUS Federal has the right to change a classification, if upon receipt, MAXIMUS
Federal determines the case was misclassified. For example, if a Medicare Health Plan submits a
standard claim payment case as expedited, MAXIMUS Federal may change the classification from
expedited to standard claim.
4.5 MEDICARE HEALTH PLAN RESPONSIBILITY TO CONDUCT A FULL
RECONSIDERATION
Medicare Health Plans are required to conduct a thorough Medicare Health Plan level
reconsideration, prior to submitting a case to MAXIMUS Federal for IRE level reconsideration.
Consult 42 CFR §422.590 and the CMS Medicare Managed Care Manual for a definition of the
Medicare Health Plan’s obligations in conducting its reconsideration. In addition, the MAXIMUS
Federal requirements and suggestions for IRE level case file preparation (See Section 5.3) will be
difficult to meet if the Medicare Health Plan has not previously undertaken and documented a full
Medicare Health Plan level reconsideration.
MAXIMUS Federal may, at its discretion, utilize the "request for additional information"
process (See Section 6.6) to direct Medicare Health Plans to remedy a case in which a complete
Medicare Health Plan level reconsideration has not occurred or has not been documented.
MAXIMUS Federal will notify CMS if a Medicare Health Plan displays a pattern of failure to
complete and document a thorough Medicare Health Plan level reconsideration.
Rev. January 2020
25
4.6 MEDICARE HEALTH PLAN RECONSIDERATION WITH INCOMPLETE
EVIDENCE
The Medicare Health Plan should gather all pertinent evidence or information before rendering
its organization determination and completing the Medicare Health Plan level reconsideration. CMS
policy dictates that a Medicare Health Plan should not automatically deny the enrollee's organization
determination request due to a lack of documentation. Therefore, if the only available information is
the enrollee's description, the Medicare Health Plan's decision must be based on that description.
1
1
The basis of the Medicare Appeals Process is the Constitutional protection of the enrollee's right to federal benefits to which
that
enrollee is entitled. The burden is therefore generally on the MA Organization to demonstrate that the enrollee is not entitled to the
denied service or claim. Absence of evidence, and most notably relevant medical records, would generally undermine the
MA
Organization’s arguments that it had demonstrated a legitimate process and basis for its denial. Possible exceptions would include non-
emergent or -urgent enrollee "self-referred" out-of-plan services, without prior related health care access request to
the MA
Organization, where the enrollee and non-contracted provider will not cooperate in the provision of records.
Rev. January 2020
26
5. SUBMITTING RECONSIDERATION CASE FILES TO MAXIMUS
FEDERAL
This Chapter defines the requirements for Medicare Health Plan preparation and submission of
case files to MAXIMUS Federal for IRE level reconsideration under the following headings:
5.1 Cases That Must Be Submitted to MAXIMUS Federal for Reconsideration
5.2 Time Standards for Submission of Cases to MAXIMUS Federal
5.3 Preparation and Submission of the New Case File to MAXIMUS Federal
5.1 CASES THAT MUST BE SUBMITTED TO MAXIMUS FEDERAL FOR
RECONSIDERATION
Federal Regulation 42 CFR §§422.590-422.592 and the CMS Medicare Managed Care
Manual, Chapter 13 define cases that must be submitted for IRE reconsideration. The Medicare Health
Plan must submit any case for which it is responsible for a Medicare Health Plan level reconsideration,
unless the Medicare Health Plan has wholly reversed its initial adverse organization determination or
dismissed the request for reconsideration. Federal regulations define a case in which the Medicare
Health Plan has failed to make a reconsideration determination by the applicable due date, as an
affirmation of the adverse organization determination. Therefore, cases in which the Medicare Health
Plan has not made a decision as of the expiration of the decision timeframe also must be submitted to
MAXIMUS Federal. If the Medicare Health Plan subsequently obtains or develops additional
information on any case (including an incomplete case), it must submit that information to
MAXIMUS Federal. However, MAXIMUS Federal will not delay its review and makes no guarantee
that such late, additional information can be taken into account prior to the MAXIMUS Federal
determination.
5.2 TIME STANDARDS FOR SUBMISSION OF CASES TO MAXIMUS FEDERAL
The following sub-sections define time standards for case submission for each reconsideration
priority (expedited, standard service, standard service Part B drug, and standard claim). Please note
that all references to the "enrollee's request" for a reconsideration should be interpreted as a valid
reconsideration request from any permissible appealing party, including representatives and
noncontract providers. However, such a request does not become valid until and unless the
documentation standards for parties and representatives are met (See Section 4.2).
5.2.1 TIMELINESS OF SUBMISSION OF EXPEDITED RECONSIDERATIONS
Federal regulations (42 CFR §422.590(d) and (e)) require the Medicare Health Plan to
complete expedited cases within 72 hours of receipt of the request, or sooner if the enrollee's health
condition requires. The Medicare Health Plan may take an extension of up to 14 calendar days, if such
extension is in the enrollee's interest.
Rev. January 2020
27
For expedited cases only, the regulations (42 CFR §422.590(d)(4)) also define an additional
interval for "submission" of the case file to MAXIMUS Federal. Submission is to occur within 24
hours of the Medicare Health Plan's completion of its reconsidered determination. The 24-hour period
permitted for submission is thus in addition to the time permitted for the Medicare Health Plan
reconsideration.
The Medicare Health Plan must submit expedited reconsideration case files to MAXIMUS
Federal via overnight/next day delivery rather than by standard mail. Expedited reconsideration case
files may also be submitted to MAXIMUS Federal through the QIC Appeals Portal.
As a practical matter, MAXIMUS Federal assumes that Medicare Health Plan reconsideration
decisions occur as of the close of the business day on which the decision is rendered. Therefore, the
Medicare Health Plan meets the 24-hour standard if it submits the case to a commercial delivery
service by that delivery vendor's close of business on the day after the Medicare Health Plan makes its
reconsideration determination.
2
The case would then be delivered to MAXIMUS Federal on the next
day that falls within the vendor's customary schedule. Exhibit 5-1: Expedited Case Submission
Timetable, contains a table illustrating how these rules apply to submission of expedited cases.
5.2.2 MAXIMUS BUSINESS HOURS AND QIC APPEALS PORTAL
AVAILABILITY
MAXIMUS Federal offices are open to receive case file submissions Monday through
Saturday. The QIC Appeals Portal is open 24 hours a day, seven days a week. Please note, however,
that MAXIMUS Federal will use the system receipt date as the date the documentation was received
when the file is received during normal business hours. Normal business hours are Monday through
Friday until 7p.m. and Saturday until 2:00p.m. If the system receipt date is outside of the MAXIMUS
Federal normal business hours, the following business day shall be used as the receipt date.
MAXIMUS Federal will pull files at least every four hours during business hours daily; the final pull
of each business day will occur between the hours of 6:00 pm and 7:00 pm (Eastern Time) daily.
2
As noted in Section 5.1, the failure of the MA Plan to make its reconsideration determination by the deadline is regarded
as an adverse determination that triggers the requirement for case submission to MAXIMUS Federal.
Rev. January 2020
28
Exhibit 5-1
EXPEDITED CASE SUBMISSION TIMETABLE
Day of Medicare Health
Plan Determination
Day of Medicare Health
Plan Case Submission to
Overnight
Delivery
Vendor
Day of MAXIMUS Federal
Receipt
Monday
Tuesday
Wednesday
Tuesday
Wednesday
Thursday
Wednesday
Thursday
Friday
Thursday
Friday
Saturday*
Friday
Saturday*
Monday
Saturday
Monday
Tuesday
*Some delivery vendors require senders to specify "Saturday Delivery" on the envelope/package to be
delivered. MAXIMUS Federal is open to receive cases on Saturday from 9:00 am to 2:00 pm (Eastern
Time).
5.2.2 TIME STANDARD FOR SUBMISSION OF STANDARD SERVICE
RECONSIDERATIONS
Regulations at 42 CFR §422.590(a)(2) require the Medicare Health Plan to submit a standard
service reconsideration to MAXIMUS Federal:
· As expeditiously as the enrollee's health condition requires, or
· Not later than 30 calendar days after the receipt of a valid reconsideration request, subject to an
additional 14-calendar day extension, if taken in the enrollee's interest, as per 42 CFR
§422.590(e).
The regulations do not provide any additional time period for submission. Also, MAXIMUS
Federal does not require the Medicare Health Plan to use overnight delivery for these cases.
Consequently, for purposes of defining and calculating timeliness, MAXIMUS Federal adds five
calendar days to the intervals listed above. For example, MAXIMUS Federal would consider a
standard service case, without an extension, to be submitted timely if it is received within 35 calendar
days of the enrollee's valid request for reconsideration.
5.2.3 TIME STANDARD FOR SUBMISSION OF STANDARD SERVICE PART B
DRUG RECONSIDERATIONS
Effective January 1, 2020, Medicare rules require Medicare Health Plans to complete standard
service Part B Drug reconsiderations no later than 7 calendar days after the receipt of a valid
reconsideration request. Standard service Part B Drug reconsiderations are not entitled to the 5-
calendar day interval for mailing noted above for regular standard service reconsiderations.
Rev. January 2020
29
For standard service Part B drug appeals, submission is to occur within 24 hours of the
Medicare Health Plan's completion of its reconsidered determination. The 24-hour period permitted for
submission is thus in addition to the time permitted for the Medicare Health Plan reconsideration.
The Medicare Health Plan must submit standard per-service Part B drug appeal
reconsideration case files to MAXIMUS Federal via overnight/next day delivery rather than by
standard mail. These reconsideration case files may also be submitted to MAXIMUS Federal through
the QIC Appeals Portal.
As a practical matter, MAXIMUS Federal assumes that Medicare Health Plan reconsideration
decisions occur as of the close of the business day on which the decision is rendered. Therefore, the
Medicare Health Plan meets the 24-hour standard if it submits the case to a commercial delivery
service by that delivery vendor's close of business on the day after the Medicare Health Plan makes its
reconsideration determination.
3
The case would then be delivered to MAXIMUS Federal on the next
day that falls within the vendor's customary schedule.
3
As noted in Section 5.1, the failure of the MA Plan to make its reconsideration determination by the deadline is regarded
as an adverse determination that triggers the requirement for case submission to MAXIMUS Federal.
Rev. January 2020
30
5.2.4 TIME STANDARD FOR SUBMISSION OF STANDARD CLAIM
RECONSIDERATIONS
Regulations at 42 CFR §422.590(b)(2) require the Medicare Health Plan to submit a standard
claim reconsideration to MAXIMUS Federal within 60 calendar days from the date of the enrollee's
request for reconsideration. The Medicare Health Plan may submit cases by standard mail. For
calculations of timeliness, MAXIMUS Federal adds 5 calendar days to the 60 days. For example,
MAXIMUS Federal would consider a standard claim case to be submitted timely if it is received
within 65 calendar days of the enrollee's valid request for reconsideration.
5.3 PREPARATION AND SUBMISSION OF THE NEW CASE FILE TO MAXIMUS
FEDERAL
Addressed below are instructions for the Medicare Health Plan on the required methods for
physical construction of a case file submitted to MAXIMUS Federal for IRE reconsideration. The
topics are addressed under the following subheadings:
5.3.1 Initiation of Expedited Cases
5.3.2 Organization of the New Case File Package
5.3.3 Organization of Individual New Case Files
5.3.4 Guidance on Selection and Inclusion of Medical Records
5.3.5 Confirmation of MAXIMUS Federal Case Receipt
As explained below, the Medicare Health Plan must include with each case a Medicare
Managed Care Reconsideration Background Data Form and a structured Case Narrative report. The
instructions for this form and report are presented in Appendix, and should be thoroughly reviewed
since the instructions are integral to an understanding of case preparation and submission
requirements.
Please note that the data entry required for submission of a case file through QIC Appeals
Portal is equivalent to the Medicare Managed Care Reconsideration Background Data Form; no
separate form needs to be submitted for case files sent via the QIC Appeals Portal. For all cases,
including those submitted via the QIC Appeals Portal, a structured Case Narrative report is required.
5.3.1 INITIATION OF EXPEDITED CASES
To protect enrollee confidentiality, Medicare Health Plans must not fax or email expedited
case files. MAXIMUS Federal will not initiate any case that is sent via facsimile until a hard copy of
the case file is received. Follow the instructions for case delivery in Section 5.3.2.
Rev. January 2020
31
5.3.2 ORGANIZATION OF THE NEW CASE FILE PACKAGE
The "New Case File Package" is the envelope or container in which the Medicare Health Plan
ships MAXIMUS Federal one or more new case files. MAXIMUS Federal offices are open to accept
case file delivery Monday through Saturday. Address packages to:
MAXIMUS Federal
Medicare Managed Care Reconsideration Project
3750 Monroe Ave. Ste. 702
Pittsford, New York 14534-1302
When submitting paper case files, the Medicare Health Plan may include more than one new
case in the package submitted to MAXIMUS Federal, but it is imperative to clearly separate individual
case files from one another to prevent issues with intermingling enrollee information.
The MAXIMUS Federal offices are open to receive case file submissions Monday through
Saturday. The QIC Appeals Portal is open 24 hours a day, seven days a week. Please note, however,
that MAXIMUS Federal will use the system receipt date as the date the documentation was received
when the file is received during normal business hours. Normal business hours are Monday through
Friday until 7:00 pm and Saturday until 2:00 pm. If the system receipt date is outside of the
MAXIMUS Federal normal business hours, the following business day shall be used as the receipt
date. MAXIMUS Federal will pull files at least every four hours during business hours daily; the final
pull of each business day will occur between the hours of 6:00 pm and 7:00 pm (Eastern Time) daily.
When submitting electronic case files using the QIC Appeals Portal, the Medicare Health Plan
may include only one new case in each package submitted to MAXIMUS Federal.
For all case file submissions:
· Complete and place the New Reconsideration Case File Transmittal Cover Sheet form (See
Appendix) on top of the case file package.
· Bind each case in the package separately; using clips or other method that can be removed
without special equipment is permissible.
· Do not staple or permanently bind case file material.
5.3.3 ORGANIZATION OF INDIVIDUAL NEW CASE FILES
The organization of the case will be in the following order, "top" of file to "bottom."
· Medicare Managed Care Reconsideration Background Data Form (See Appendix)
· Case Narrative (See Appendix)
· Case Material (See Exhibit 5-2)
Rev. January 2020
32
Exhibit 5-2
EXPLANATION OF "CASE MATERIAL"
"Case material" refers to all supporting notices, documentation, medical records, call logs, and
so forth. Case material should be placed in a standard order, "top" of file to "bottom," as shown below.
·
Notices
o
Appointment
of
Representative (if
applicable)
o
Non
-
Contract
Provider
Waiver
of
Liability
(if
applicable)
o
Notice
of
Medicare
Health
Plan
Adverse
Organization
Determination
o
Notice
of
Medicare
Health
Plan
Reconsideration
Determination
o
Notice
of
Denial
of Expedited
Appeal
Request (if applicable)
o
Notice
of
Extension
to
timeframe
taken
in
enrollee
interest (if
applicable)
·
Record of Adverse Determination and Medicare Health Plan Reconsideration
o
Prior
authorization
or
claim
denial
documents
o
Medical
Director or
consultant
determinations
o
Documentation
of
arguments
of enrollee,
enrollee's
provider
or
representative
o Any provider letters of support or consultations supporting the enrollee's
position
o
Any
relevant
call
logs
or
system
reports
o Any other records kept by the Medicare Health Plan of its initial determination
or
reconsideration
proceeding
·
Medicare Health Plan Decision Making Criteria
o
Complete
copy
of
subscriber
agreement,
preferably
on
CD
-
ROM
o
Full
citation
for
any
CMS
policy
references,
or
copy
of
text
4
o
Other
Information
o
Complete
copy
of
any
referenced
internal
medical
policy,
utilization
review
criteria,
technology
assessment,
or
other
cited
medical
criteria
·
Medical Records (See Section 5.3.4)
4
"Full citation" refers to the designation of section and paragraph of the Social Security Act or CFR, CMS Manual
Section/Page; a copy is not required for these citations. For Local Coverage Decisions, a copy must be included unless
an active and complete citation is provided via direction to a web address. Do not cite to secondary sources (for
example, MCG/Milliman, InterQual, or proprietary internal policies) unless complete text is provided.
Rev. January 2020
33
5.3.4 GUIDANCE ON SELECTION AND INCLUSION OF MEDICAL RECORDS
For denials that are based, in whole or part, on medical necessity, the Medicare Health Plan is
burdened with the requirement to provide a "peer defensible" rationale for the denial. Medical records
that relate to the case issues must be included. Medical records that do not relate to the case should not
be included.
If the Medicare Health Plan has made one or more unsuccessful attempts to obtain records,
such attempts should be documented. For example, the Medicare Health Plan may include a statement
within the Case Narrative (Section IV (B) Justification) detailing the attempts made to obtain the
records and the basis of why the Medicare Health Plan arrived at its decision without these records.
Medicare allows MA plans to use step therapy for Medicare Part B drugs to manage its
formulary. This is the process of beginning drug therapy for a medical condition with "preferred" (or
more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as
necessary. A plan must grant an exception to its step therapy coverage rules for Medicare Part B drugs
if it determines that the requested drug is medically necessary, consistent with the prescriber's
statement and the medical records. The physician statement and the medical records must show that
the step therapy drugs:
1. have been ineffective in treating the enrollee; or
2. are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or
3. are likely to cause an adverse reaction or other harm to the enrollee.
The documentation required in the case file from the plan is as follows:
o Plan specific plan Step Therapy rules
o Enrollee physician statement regarding trial and failure of specific medications Enrollee
medical records regarding previous treatments
o Entire Evidence of Coverage /Plan Formulary and any addendums regarding Medicare Part B
Drugs.
Exhibit 5-3: Suggested Medical Records for Inpatient and Long-term Care Denials and Exhibit 5-4:
Suggested Medical Records for Other Common Types of Denials are offered by MAXIMUS Federal to
reduce the need for requests for additional information to the Medicare Health Plan. The Medicare
Health Plan should regard Exhibits 5-3 and 5-4 as a general guide. Requirements for a given case may
vary. MAXIMUS Federal reserves the right to request records in addition to those listed in Exhibit 5-3
and/or 5-4 should the situation warrant the request.
Exhibit 5-3
SUGGESTED MEDICAL RECORDS FOR INPATIENT AND LONG-TERM CARE DENIAL
Medical Records
Acute Hospital
Admission Denial
Acute Hospital Continued
Care Denial
SNF Admission
Denial
SNF Continued Care
Denial
Inpatient Rehabilitation
Admission Denial
Inpatient Rehabilitation
Continued Care Denial
PCP Records X
Specialist
Records
X
Treating Physician Support For
Denial
X
X
X
X
X
X
Alternate Care
Recommendations
X
X
X
X
X
X
Pre-Admission Screening
X X
Admission Orders*
X
X
(hospital)
X
(SNF)
X
(hospital
or
SNF)
X
(rehab)
Doctor's Orders*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Admission History and
Physical*
X
X (hospital)
X
X (hospital or SNF)
X (rehab)
Discharge Note*
X X (hospital) X (hospital) X (hospital or SNF) X (hospital, SNF, rehab)
Physician
Progress
Notes*
X
X
(hospital)
X
(hospital
and
SNF)
X
(hospital
or
SNF)
X
(rehab)
Nurses
Notes*
X
X
(hospital)
X
(SNF)
X
(hospital
or
SNF)
X
(rehab)
Nursing Care Plan*
X
X (SNF) X (hospital or SNF) X (rehab)
Medication Record*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Treatment Records (e.g.,
wound care) *
X
X (hospital)
X (SNF)
X (hospital or SNF)
X (rehab)
Diagnostic Studies*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Laboratory Studies*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Physical Therapy Admission
and Discharge Notes*
X (SNF)
X (hospital or SNF)
X (rehab)
Physical Therapy Progress
Records*
X
X (hospital)
X (hospital and SNF)
X (hospital or SNF)
X (rehab)
Occupational Therapy
Admission and Discharge
Notes*
X (SNF)
X (hospital or SNF)
X (rehab)
Occupational Therapy
Progress Records*
X
X (hospital)
X (hospital and SNF)
X (hospital or SNF)
X (rehab)
Speech Therapy Admission
and Discharge Notes*
X (SNF)
X (hospital or SNF)
X (rehab)
Speech Therapy Progress
Notes*
X
X (hospital)
X (hospital and SNF)
X (hospital or SNF)
X (rehab)
Nutrition Therapy Notes*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Discharge Planning Notes*
X X (hospital) X (SNF) X (hospital or SNF) X (rehab)
Records on prior level of
functioning
X
X
X
X
* Records may be from an acute care hospital, a SNF, or an inpatient rehabilitation facility depending on the case types and basis for denial.
Exhibit 5-4
SUGGESTED MEDICAL RECORDS FOR OTHER COMMON TYPES OF DENIALS
Issue at Appeal Records needed
Mobility Aids (PMDs, power wheelchairs, manual
wheelchairs, walkers, canes)
PCP records, Physical Therapy records, Orthopedic records, Neurology records (if applicable), face-to-
face, in-home DME evaluations
MRIs PCP records, Orthopedic Records, Neurology Records, Physical Therapy Records
CT Scans PCP records, neurology records, other specialties as needed
Cataract surgery PCP records, ophthalmology records
Blepharoplasty PCP records, ophthalmology records including visual fields (taped and untaped) and photographs
PET scans PCP records, oncology records
Rehabilitation Therapy PCP records, physical therapy records, initial assessment and treatment plan
Oxygen Equipment PCP records, pulmonology records, O2 saturation test results
Chiropractic care PCP records, orthopedic records (if applicable), neurology records (if applicable), x-rays/x-ray reports
Colonoscopies (including cost sharing cases) Colonoscopy report, PCP records, gastroenterology records
Foot Care PCP records, Podiatry records , Endocrinology records (if applicable)
Radiation Therapy/Chemotherapy
PCP records, Oncology records, lab results, surgery records (if applicable)
Bone Growth Stimulators PCP records, orthopedic records, x-rays/x-ray reports
Specialist services (general) PCP records, records from specialist type at issue
Emergency Room and Ambulance Transport ER records, ambulance trip reports, nurse’s notes, ER triage/intake notes
Mental Health Services PCP records, Psychiatry records, Psychology/Social Worker notes, Behavioral Health notes
Bariatric Surgery PCP notes, Bariatric Surgery notes, Nutritionist notes, Endocrinology notes (if applicable)
Dental Services Dental Records, Oral Surgery Records, Dental x-rays (preferably photo-quality digital prints)
Part B covered drugs PCP records, requesting physician records
Part B covered drugs/Part B Step Therapy Drug Plan requirements involving step therapy analysis, enrollee physician statement, complete medical records
regarding previous treatments, full Evidence of Coverage with Plan Formulary
Rev. January 2020 34
5.3.5 CONFIRMATION OF MAXIMUS FEDERAL CASE RECEIPT
MAXIMUS Federal does not accept responsibility for loss or delay of case files caused by
the US Mail or other delivery services. We do attempt to notify Medicare Health Plans and the other
party to the appeal of receipt of case files, as follows:
Standard Service and Claim Cases
MAXIMUS Federal sends the Medicare Health Plan and appealing party an
acknowledgement letter by regular first class mail within two (2) business days of our receipt of the
case file. Allowing for time for delivery of the Medicare Health Plan case to MAXIMUS Federal,
the Medicare Health Plan should contact MAXIMUS Federal if it has not received the
acknowledgement letter within 10 business days of its case submission.
Dismissal Review Cases
MAXIMUS Federal does not send an acknowledgement letter for these types of cases.
When the request for a review of the Medicare Health Plan’s dismissal is received, MAXIMUS
Federal will request the case file from the Medicare Health Plan. Our receipt of the file is confirmed
by the appealing party’s and Medicare Health Plan’s receipt of our reconsideration determination
notice (See Section 8).
Cases submitted via the QIC Appeals Portal (all priorities and case types)
When a case file is submitted to MAXIMUS Federal via the QIC Appeals Portal, the Medicare
Health Plan will receive immediate on-screen acknowledgement that the documents have been
received by MAXIMUS Federal, as well as a follow-up e-mail confirmation of receipt.
Confirmation will include a tracking number.
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Rev. January 2020
6. MAXIMUS FEDERAL RECONSIDERATION PROCESS
The purpose of this Chapter is to provide the Medicare Health Plan with an overview of the
procedures and approach that MAXIMUS Federal follows in rendering the IRE level
reconsideration. Although the focus is on MAXIMUS Federal procedures, implications for the
Medicare Health Plan are highlighted in text contained in shaded boxes. The topics addressed are:
6.1 MAXIMUS Federal Case Processing Time Standards
6.2 Administrative Case Intake
6.3 Policies on Communication with Medicare Health Plan and Appellant during Case
Processing
6.4 Adjudicator Case Review
6.5 Physician Review
6.6 Requests to Medicare Health Plan for Additional Information
6.7 Reconsideration Determination Notices
6.8 Enrollee Requests for Case Files
6.1 MAXIMUS FEDERAL CASE PROCESSING TIME STANDARDS
MAXIMUS Federal is responsible for completing the IRE reconsideration within the same
timeframes and standards that apply to Medicare Health Plans.
CASE
CLASS
TIME STANDARD
Expedited
72 hours, plus 14 calendar day extension if in enrollee’s interest, or
sooner
if
warranted
by
enrollee’s
medical
condition
Standard Service
30 calendar days, plus 14 calendar day extension if in enrollee’s
interest,
or
sooner
if
warranted
by
enrollee’s
medical
condition
Standard Service
Part B Drug
7 calendar days- no extensions are permitted for these case types
(effective January 1, 2020)
Standard Claim
60 calendar days
In expedited and standard service appeals, MAXIMUS Federal may extend the decision
timeframe by up to 14 calendar days if it is in the enrollee's interest. This 14-day extension is not
permitted for standard service Part B drug appeals. MAXIMUS Federal will notify the enrollee and
Medicare Health Plan of the extension in writing.
The start of the time period for IRE reconsideration is the date on which the case file is
received at MAXIMUS Federal. The end of the time period is the date on which MAXIMUS
Federal mails its reconsideration determination notice. Determinations are sent to appellants by
standard first class mail and faxed to Medicare Health Plans.
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6.2 ADMINISTRATIVE CASE INTAKE
The steps in MAXIMUS Federal administrative case intake are:
· Mail Opening and sorting of new case files
· Inquiry on CMS systems to verify beneficiary enrollment in Medicare Health Plan
· Medicare Appeal System assignment of a random "reconsideration case number"
· Generation of acknowledgement letters (standard service and claim only)
· Assignment of the case to a MAXIMUS Federal Adjudicator
See Section 5.3.5 for the discussion of acknowledgement letters and response the Medicare
Health Plan should take if a letter is not received.
6.3 POLICIES ON COMMUNICATION WITH MEDICARE HEALTH PLAN AND
APPELLANT DURING CASE PROCESSING
6.3.1 ALL EVIDENCE MUST BE IN WRITING
Federal regulations define the IRE level reconsideration as a de novo determination based
upon the documented case file. The IRE level reconsideration does not provide for in-person or
telephonic hearings. This means that MAXIMUS Federal may consider only such evidence as is
submitted and available in the hard copy record.
6.3.2 COMMUNICATIONS REGARDING THE POTENTIAL IRE
DETERMINATION ARE NOT PERMITTED
MAXIMUS Federal personnel are not permitted to engage in written or phone
communication with parties, where the subject of such communication is any discussion or
projection of the IRE determination that MAXIMUS Federal may make. Discussions are limited to
review of the IRE process, including instructions on the procedures for submission of written
information to MAXIMUS Federal.
6.3.3 ENROLLEE SUBMISSION OF ADDITIONAL INFORMATION TO THE
IRE CASE FILE
Note that our ability to accomplish case intake is compromised if the Medicare Health Plan
does not
provide the enrollee's Medicare number and all other required fields on the
Reconsideration Background Data Form (See Appendix). Errors or omissions on the
Reconsideration Background Data Form will lead to delays in MAXIMUS Federal intake of
the case.
If any party calls MAXIMUS Federal, they are advised that the information they relay will
not be considered unless it is submitted in writing. The party is advised that he/she should
follow up any "telephone testimony" immediately with written documentation.
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Rev. January 2020
The MAXIMUS Federal acknowledgement letter that is sent to the enrollee or valid
representative, advises the enrollee of their ability to submit information or arguments directly to
MAXIMUS Federal. The acknowledgement letter is not used for expedited cases or standard
service Part B Drug cases. For standard service and standard claim reconsiderations (not standard
service Part B drug cases), the enrollee is given 10 days to submit information to MAXIMUS
Federal.
MAXIMUS Federal may provide a Medicare Health Plan information that the Medicare
Health Plan has submitted, but MAXIMUS Federal may not provide information submitted by the
enrollee. If information submitted by the enrollee is not already contained in the case file, and if the
information calls into question material submitted by the Medicare Health Plan, MAXIMUS
Federal may request clarification via a Request for Information (See Section 6.6).
Enrollees may be less likely to submit information directly to MAXIMUS Federal if the
enrollee believes that: (1) the Medicare Health Plan has provided the enrollee the chance to submit
evidence to the Medicare Health Plan and (2) the Medicare Health Plan has advised the enrollee that
the entire case file has been submitted to MAXIMUS Federal.
6.4 ADJUDICATOR CASE REVIEW
An Adjudicator is a professional trained by MAXIMUS Federal to: (1) manage the IRE case
reconsideration and (2) make coverage determinations. Adjudicators are not permitted to make
medical necessity determinations, which require physician review (See Section 6.5).
6.5 PHYSICIAN REVIEW
Pursuant to 42 CFR §422.590(h)(2), determinations of medical necessity must be made by a
physician, where physician is defined to include doctors of chiropractic and osteopathy. MAXIMUS
Federal maintains a panel of over 800 medical consultants who are fully credentialed to the
standards of our accrediting body, URAC. These medical consultants are located throughout the
United States and include a mix of physicians who predominately practice in community rather than
academic settings.
The MAXIMUS Federal medical consultants cover all specialties and all relevant sub-
specialties recognized by the American Board of Medical Specialties (ABMS). Physicians are
matched to cases based upon the case clinical issue. For most cases, this means that the specialty of
the MAXIMUS Federal reviewer is the same as the specialty of the physician who would render the
contested service. In cases in which the issue is the appropriateness of a referral from one specialist
to another (for example, internal medicine to dermatology), MAXIMUS Federal may choose to use
the specialty of the referring physician.
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Rev. January 2020
The physician consultant's report is reviewed by the Adjudicator and, if need be, the
MAXIMUS Federal Medical Director. Special emphasis is placed on ensuring that the consultant's
determination is consistent with any relevant Medicare policies or permissible and medically
appropriate Medicare Health Plan policies.
6.6 REQUESTS TO MEDICARE HEALTH PLAN FOR ADDITIONAL
INFORMATION
"Request for Additional Information" (RI) is the formal process by which MAXIMUS
Federal permits the Medicare Health Plan to supply written information to remedy a question or
deficiency in the reconsideration case file.
6.6.1 REQUEST FOR ADDITIONAL INFORMATION IS AT MAXIMUS
FEDERAL DISCRETION
The MAXIMUS Federal reconsideration is designed as an "on the record" review rather
than an "in person" proceeding. Therefore, the Medicare Health Plan reconsideration case file must
include all materials submitted and used in making the Medicare Health Plan reconsideration
determination and all such material as is specified in Section 5.3.
The IRE is under no obligation to seek additional information. The Medicare Health Plan
bears the burden to show why the denial is appropriate. Therefore, missing information is
reasonably construed to the enrollee’s favor. MAXIMUS Federal may decide a case at any time
based upon the information available. MAXIMUS Federal does not overturn the Medicare Health
Plan’s denial for case file deficiencies, per se, or on an administrative basis. However, a case file
deficiency typically undermines the validity of denial argument of the Medicare Health Plan, hence
missing information may result in a determination that is favorable to the appellant.
The Adjudicator referral to the physician includes a copy of and, where necessary,
guidance
regarding any applicable Medicare National Coverage Decision (NCD), local
coverage
decision (LCD) or clinical guidelines. Where the Medicare Health Plan medical
necessity determination is based upon a Plan guideline, such guideline and any relevant
background from the Medicare Health Plan (including literature from recognized medical
publications) will be emphasized to the MAXIMUS Federal reviewer. Medicare Health
Plans must
include Plan guidelines for this reason.
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Rev. January 2020
6.6.2 REQUEST FOR INFORMATION PROCESS
The process used by MAXIMUS Federal for Request for Information is as follows:
· The Adjudicator determines the deficiency and double checks the case file to verify the
information is, in fact, absent
· The Adjudicator sends a completed Request for Information Form to the fax number or
email address provided for the Case Contact on the Reconsideration Background Data
Form
· The Medicare Health Plan Case Contact calls MAXIMUS Federal if:
· Questions exist about the RI
· The RI deadline (See Section 6.6.3) cannot be met
· The Medicare Health Plan develops and submits the RI Response
· The Adjudicator reviews the RI response to determine if it is sufficient. If not:
· Minor omissions are resolved by phone
· Major omissions may lead to a repeat of the RI process or may lead to MAXIMUS Federal
determination based on available documents.
6.6.3 MEDICARE HEALTH PLAN SUBMISSION OF THE RESPONSE TO A
REQUEST FOR INFORMATION
To protect patient confidentiality in accordance with federal standards, the Medicare Health
Plan must not transmit confidential information to MAXIMUS Federal by email or fax. All
confidential information must be submitted to MAXIMUS Federal by hard copy mail or delivery.
For purposes of this discussion, the MAXIMUS Federal assigned reconsideration number is not
considered confidential information.
· If hard copy delivery is used for an RI response, the Medicare Health Plan must place the
Request for Information Response Cover Sheet (see Appendix) on top of the response
documents.
· If the Medicare Health Plan places more than one RI response in a package, separate each
RI response with the Request for Information Response Cover Sheet.
The Medicare Health Plan may respond to a Request for Information by fax if the Medicare
Health Plan can fully address the RI requirements without use of confidential identifiers, or by
redacting such identifiers.
The following maximum timeframes apply for Medicare Health Plan response to
MAXIMUS Federal Requests for Information:
Expedited reconsiderations within 3 calendar days from date of request
Standard Service reconsiderations within 5 calendar days from date of request
Standard Service Part B Drug reconsiderations within 24 hours from date of request
Standard Claim reconsiderations within 10 calendar days from date of request
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Rev. January 2020
The above timeframe deadline is for the date of Medicare Health Plan submission (mailing
or fax) of the material to MAXIMUS Federal. Expedited RI responses and Standard Service Part B
Drug Reconsideration RI responses must be submitted by fax (if material does not contain
confidential information), portal, or by overnight delivery.
MAXIMUS Federal may expedite an RI request if such action is necessary due to the
enrollee's health.
6.7 RECONSIDERATION DETERMINATION NOTICES
6.7.1 ISSUING A RECONSIDERATION DETERMINATION
Upon completion of its reconsideration, MAXIMUS Federal issues a "reconsideration
determination" notice to the appealing party, with a copy to the Medicare Health Plan and the CMS
Regional Office.
6.7.2 GENERAL CHARACTERISTICS OF MAXIMUS FEDERAL
DETERMINATION NOTICES
All MAXIMUS Federal reconsideration determination notices that are not fully in the
enrollee's favor contain an explanation of the enrollee's right to request further appeal by the Office
of Medicare Hearings & Appeals (OMHA). This review can include a Hearing with an
Administrative Law Judge (ALJ) or an on-the-record review by an Attorney Adjudicator. A Hearing
is a meeting with you and the ALJ so that you can talk about your appeal. An on-the- record review
is a review based on the administrative record. Enrollees can ask for the kind of review that they
prefer.
A MAXIMUS Federal reconsideration determination notice that overturns a Medicare
Health Plan determination, in whole or in part, contains an explanation of how the enrollee can
obtain the disputed payment or covered service. The enrollee is directed to the Medicare Health
Plan to obtain the service or claim payment.
Although a MAXIMUS Federal reconsideration determination may address or discuss
medical care and treatments, the MAXIMUS Federal reconsideration determination is not an
assessment of quality of care, nor is it medical advice or instruction. A MAXIMUS Federal
determination is a ruling on the Medicare Health Plan's obligation for coverage (payment or
arrangement for a specific benefit, service, or treatment).
For any full or partial overturn determination, MAXIMUS Federal also issues to the
Medicare Health Plan a Notice to Comply with IRE Part C Reconsideration Determination. This
document references the overturn determination notice and advises the Medicare Health Plan of its
obligation to effectuate the overturn decision.
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Rev. January 2020
6.7.3 TRANSLATION OF CORRESPONDENCE
Upon request of the enrollee or Medicare Health Plan, MAXIMUS Federal is required by
CMS to translate its final reconsideration determination notice into the native language of the
enrollee. The Medicare Health Plan notifies MAXIMUS Federal of the need for translation on the
Reconsideration Background Data Form (See Appendix).
6.7.4 PROVISION OF COMMUNICATION IN ALTERNATE FORMATS
MAXIMUS Federal is required by CMS to arrange to provide communication in alternate
formats, if needed. The Medicare Health Plan notifies MAXIMUS Federal of the need for alternate
formats on the Reconsideration Background Data Form (See Appendix).
6.8 ENROLLEE REQUESTS FOR CASE FILES
The MAXIMUS Federal acknowledgement letter and brochure advise enrollees of the right
to obtain a copy of the reconsideration case file from the Medicare Health Plan and/or MAXIMUS
Federal. Under instruction from CMS, and subject to the provisions of the Privacy Act and Freedom
of Information Act, MAXIMUS Federal will release a copy of a reconsideration case file to an
enrollee or other authorized individual.
MAXIMUS Federal may release to a Medicare Health Plan only copies of documentation
the Medicare Health Plan has submitted in the case file.
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Rev. January 2020
7. POST RECONSIDERATION DETERMINATION PROCESSING
A number of processes may be invoked after MAXIMUS Federal issues its reconsideration
determination notice. This Chapter provides useful information on these various post determination
processes. The topics addressed are:
7.1 MAXIMUS Federal Monitoring of Medicare Health Plan Compliance with
Overturned Determinations
7.2 IRE Reopening Process
7.3 Administrative Law Judge (ALJ) Process
7.4 Medicare Appeals Council (MAC) Process
7.1 MAXIMUS FEDERAL MONITORING OF MEDICARE HEALTH PLAN
COMPLIANCE WITH OVERTURNED DETERMINATIONS
Compliance ("effectuation") is defined as the Medicare Health Plan's payment of a claim
(overturned standard claim denial), or authorization and arrangement for a service or continuation of
services (overturned expedited, standard service denial, or standard service Part B drug denial), as
instructed in the MAXIMUS Federal reconsideration determination notice.
7.1.1 MEDICARE HEALTH PLAN EFFECTUATION TIMEFRAMES
The following table summarizes CMS requirements for timeliness of Medicare Health Plan
effectuation:
APPEAL
PRIORITY
TIME REQUIREMENT (from receipt of
notice)
REFERENCE
Expedited
Authorize or provide within 72 hours, or
earlier
if
enrollee
health
dictates
42
CFR
§422.619(b)
Standard
Service
Authorize within 72 hours, or provide
within 14
days, or earlier if enrollee health dictates
42
CFR
§422.618(b)(1)
Standard
Service
Part B Drug
Authorize within 72 hours, or provide
within 14
days, or earlier if enrollee health dictates
42
CFR
§422.618(b)(1)
Standard
Claim
Pay
within
30
days
42
CFR
§422.618(b)(2)
If you have questions regarding a MAXIMUS Federal determination, please send your
request to the Plan Liaison at medicareappeal@maximus.com .Please note MAXIMUS Federal is not
authorized to waive compliance with any final determination. If you feel that you cannot comply
with the MAXIMUS Federal reconsideration determination notice, you must notify your Account
Manager at the CMS Regional Office.
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Rev. January 2020
A Medicare Health Plan request for a reopening (See Section 7.2), whether granted by
MAXIMUS Federal or not, does not stay or pend the date of the Medicare Health Plan compliance
obligation.
7.1.2 MAXIMUS FEDERAL RECONSIDERATION COMPLIANCE
MONITORING
CMS requires MAXIMUS Federal to monitor Medicare Health Plan compliance with the
effectuation process, via the following procedure:
1. MAXIMUS Federal issues the Medicare Health Plan a copy of the reconsideration
determination notice. Included with this copy is a Notice to Comply with IRE Part C
Reconsideration Determination, that details the Medicare Health Plan's responsibilities,
including the timeframe by which a compliance notice must be received by MAXIMUS
Federal
2. The Medicare Health Plan is required to submit a statement attesting to compliance
(effectuation) to MAXIMUS Federal. The Statement must be submitted to MAXIMUS
Federal in accordance with timeframes noted within the Notice to Comply with IRE Part C
Reconsideration Determination.
3. MAXIMUS Federal provides 5 days from the due date of submission for mailing time.
4. If MAXIMUS Federal does not receive the Medicare Health Plan statement of compliance
within 30 days, MAXIMUS Federal reports the Medicare Health Plan's failure to comply to
CMS. The Medicare Health Plan is not copied on this report to CMS.
The Medicare Health Plan statement of compliance may be in a form designed by the
Medicare Health Plan, but must contain all of the information found on the recommended Medicare
Health Plan Statement of Compliance Form contained in the Appendix. Please do not submit
unidentified internal computer screen prints as the statement of compliance.
Medicare Health Plan Statements of Compliance should be sent to:
MAXIMUS Federal
Medicare Managed Care Reconsideration Project
Attn: Compliance
3750 Monroe Ave. Ste. 702
Pittsford, NY 14534-1302
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Rev. January 2020
7.2 IRE REOPENING PROCESS
An IRE Reopening is an administrative procedure in which the IRE re-evaluates its
reconsideration determination for the purpose of addressing an error, fraud, or information not
available at the time of IRE initial determination. A reopening is not an appeal right.
MAXIMUS Federal may accept or reject a request for a reopening at its sole discretion.
Within 30 calendar days of receipt of a request for reopening, MAXIMUS Federal will make a
determination as to whether or not it shall reopen a case and inform the appellant and the plan of
that determination.
MAXIMUS Federal may initiate a reopening on its own initiative. In addition, any of the
parties to a reconsideration determination may request a reopening. The reopening request must be
in writing and clearly state the basis on which the request is made:
1. Error on the face of the evidence by MAXIMUS Federal in its review,
2. Fraud, or
3. New and additional information that was not available at the time MAXIMUS Federal made
its initial determination in the case.
The process by which MAXIMUS Federal administers and adjudicates a reopening request
is similar to the reconsideration process:
1. MAXIMUS Federal receives and logs the Reopening Request.
2. An acknowledgement letter is sent to the party and Medicare Health Plan.
3. An Adjudicator not involved in the reconsideration reviews the Reopening.
4. The Adjudicator makes a determination, incorporating a physician review if indicated.
5. A Reopening Determination Notice is issued.
6. If the Reopening Determination reverses a reconsideration Unfavorable (that is, the
Reopening finds in favor of the enrollee), a Notice to Comply with IRE Part C
Reconsideration Determination is also issued to the Medicare Health Plan. The Medicare
Health Plan is then responsible for "effectuation" per the discussion of compliance in
Section 7.2 above.
A Medicare Health Plan's request for a reopening does not relieve the Medicare Health Plan
of the burden of compliance, and reporting of compliance, within the required timeframes (See
Section 7.2). The Medicare Health Plan is relieved of this burden if the Medicare Health Plan
obtains a Reopening Reversal (of a Favorable reconsideration) prior to the Medicare Health Plan
compliance date. The Medicare Health Plan is not relieved of the burden of compliance with the
original favorable reconsideration if the Medicare Health Plan receives a Reopening Reversal after
the original compliance date.
MAXIMUS Federal’s contract with CMS allows 120 days for the processing of Reopening
cases. In many cases, especially those requiring physician review, the full timeframe may be
required. However, MAXIMUS Federal endeavors to process Reopenings within the same time
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Rev. January 2020
standards that are applied to reconsiderations whenever possible. Special consideration is given to
Reopenings of Expedited cases.
7.3 OFFICE OF MEDICARE HEARINGS AND APPEALS (OMHA) PROCESS
The appellant (enrollee, his/her representative, or the non-contract provider) may request an
appeal of the MAXIMUS Federal reconsideration determination before an Administrative Law
Judge (ALJ) or Attorney Adjudicator (AA) with the Office of Medicare Hearings and Appeals.
MAXIMUS Federal does not determine an enrollee's right to a hearing, nor does it schedule,
conduct, or administer hearings.
The Medicare Health Plan does not have a right to request a review by OMHA. The
Medicare Health Plan does have the right to be present at the ALJ hearing and the right to present
additional evidence at the hearing.
7.3.1 NOTICE OF RIGHTS TO HEARING AND SUBMISSION OF REQUEST
FOR ALJ OR AA HEARING
The right to request an ALJ or AA hearing is explained in the MAXIMUS Federal
reconsideration determination notice and brochure. An enrollee may submit a written request for an
ALJ or AA hearing to MAXIMUS Federal. If the Medicare Health Plan receives a request for an
ALJ or AA hearing, it should immediately forward the request to MAXIMUS Federal.
MAXIMUS Federal forwards the reconsideration case file to the appropriate Office of
Medicare Hearings and Appeals. MAXIMUS Federal does not communicate directly with Medicare
Health Plans or parties during the OMHA review process. MAXIMUS Federal’s role is limited to
providing complete case files to the OMHA office.
7.3.2 TRACKING AND CONDUCT OF ALJ OR AA HEARING
MAXIMUS Federal does not schedule ALJ or AA hearings and does not have direct access
to OMHA scheduling information. The Office of Medicare Hearings and Appeals is responsible for
contacting the requesting party and Medicare Health Plan to schedule the matter before the ALJ.
Both parties (that is, requesting party and the Medicare Health Plan) have a right to be present and
present testimony at the ALJ hearing. Any concerns regarding the ALJ hearing should be directed to
the Office of Medicare Hearings and Appeals.
7.3.3 ALJ OR AADETERMINATION PROCESSING
The ALJ or AA Determination is mailed directly to both parties (enrollee and Medicare
Health Plan). The Office of Medicare Hearings and Appeals returns a copy of the ALJ or AA
decision and the complete case file to MAXIMUS Federal. MAXIMUS Federal reviews the ALJ or
AA determination for two purposes:
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Rev. January 2020
1. MAXIMUS Federal determines whether the Medicare Health Plan was given the
opportunity to appear at the Hearing. If not, MAXIMUS Federal informs the Medicare
Health Plan.
2. If the ALJ has reversed or modified MAXIMUS Federal reconsideration determination,
MAXIMUS Federal sends a copy of the ALJ determination to the Medicare Health Plan
with a Notice to Comply with the Administrative Law Judge Determination. MAXIMUS
Federal also sends a copy of this notice to the appealing party.
The Medicare Health Plan is obligated to effectuate the ALJ's determination as
expeditiously as the enrollee's health condition requires, but no later than 60 calendar days from the
date it receives notice reversing the organization determination. The Medicare Health Plan must
report the compliance to MAXIMUS Federal in the same manner as for a MAXIMUS Federal
reconsideration reversal.
7.3.4 EFFECT OF MEDICARE APPEALS COUNCIL REQUEST ON ALJ
DECISION EFFECTUATION
If the Medicare Health Plan requests Medicare Appeals Council (Appeals Council) review
consistent with 42 CFR §422.608, the Medicare Health Plan may await the outcome of the review
before it pays for, authorizes, or provides the service under dispute. A Medicare Health Plan that
files an appeal with the Appeals Council must concurrently send a copy of its appeal request and
any accompanying documents to the enrollee and must notify the MAXIMUS Federal that it has
requested an appeal before the Appeals Council.
7.4 MEDICARE APPEALS COUNCIL PROCESS
Federal regulations permit any party to an ALJ hearing to request a further hearing before
the Appeals Council (See 42 CFR §422.608). If a hearing before the Appeals Council is requested,
MAXIMUS Federal is contacted by the Appeals Council to provide a copy of the entire case file in
dispute. MAXIMUS Federal does not communicate directly with Medicare Health Plans or parties
regarding the Appeals Council review process. MAXIMUS Federal’s role is to provide complete
case files to the Appeals Council.
7.4.1 TRACKING AND CONDUCT OF MEDICARE APPEALS COUNCIL
HEARING
MAXIMUS Federal does not schedule Appeals Council hearings and does not have direct
access to Appeals Council scheduling information. Any concerns regarding the Appeals Council
hearing process should be directed to the Medicare Appeals Council.
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7.4.2 MEDICARE APPEALS COUNCIL DETERMINATION PROCESSING
The Appeals Council Determination is mailed directly to both parties (enrollee and
Medicare Health Plan). The Medicare Health Plan is obligated to effectuate the Appeal Council's
determination as expeditiously as the enrollee's health condition requires, but no later than 60
calendar days from the date it receives notice reversing the organization determination. The
Medicare Health Plan must report the compliance to MAXIMUS Federal in the same manner as for
a MAXIMUS Federal reconsideration reversal.
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8. HEALTH PLAN DISMISSAL PROCESSING AND APPEALS
Effective January 1, 2014, Medicare Health Plans are not required to automatically forward
dismissed reconsideration requests to MAXIMUS Federal. Rather, Medicare Health Plans are
required, when dismissing an appellant’s reconsideration request, to inform the appellant about the
right to request IRE review of the dismissal. CMS guidance explicitly states that Medicare Health
Plans should use the model Notice of Dismissal of Appeal Request to advise appellants when their
request is being dismissed. Appellants will then have the right to request a review of the Medicare
Health Plan’s dismissal determination directly to MAXIMUS Federal. Plans should include the
model dismissal appeal request form with all dismissals. This form is intended to standardize
incoming dismissal appeal requests and to provide MAXIMUS Federal with the information
necessary to initiate the appeal request and case file request from the plan. Additional information is
provided in 8.1. Topics discussed in this section are:
8.1 Notice of Dismissal of Appeal Request
8.2 Dismissal Case File Requests
8.3 MAXIMUS Federal Review of Dismissal Decision
8.4 Dismissal Case File Documentation
8.5 Timeframes for MAXIMUS Federal Review
8.6 Dismissal Decisions are binding
8.1 NOTICE OF DISMISSAL OF APPEAL REQUEST
The Notice of Dismissal of Appeal Request provides MAXIMUS Federal with sufficient
information to begin processing an appellant’s dismissal review request. MAXIMUS Federal
recommends that Medicare Health Plans include either the Medicare Health Plan appeal case
number or the date of services on the Notice of Dismissal of Appeal Request.
Appellants should either fax or mail a copy of this Notice of Dismissal of Appeal Request,
along with any supporting documentation relevant to the review request, directly to MAXIMUS
Federal.
Plans should include the model dismissal appeal request form with dismissals. If the plan
has the ability to populate information in this form (e.g., names, dates of service), MAXIMUS
Federal recommends that plans do so. Plans should customize this form to include their Plan
information and a fax number for MAXIMUS Federal to utilize to request a case file. The model
form is included in Appendix A.
8.2 DISMISSAL CASE FILE REQUESTS
Once MAXIMUS Federal receives a dismissal review request from the appellant,
MAXIMUS Federal will contact, via fax, the individual or department that the Medicare Health
Plan has listed on the Notice of Dismissal of Appeal Request as the party responsible for providing
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a copy of the case file to MAXIMUS Federal. Per CMS guidance, Medicare Health Plans will have
24 hours from receipt of the case file request to forward the requested case file to MAXIMUS
Federal. CMS permits a 5-day mailing window for receipt of case files.
8.3 MAXIMUS FEDERAL REVIEW OF DISMISSAL DECISION
Once MAXIMUS Federal has received the case file from the Medicare Health Plan,
MAXIMUS Federal will review the contents of the file and the Notice of Dismissal of Appeal
Request, along with any supplemental information submitted by the appellant. After this review,
MAXIMUS Federal will determine if the Medicare Health Plan’s dismissal was appropriate. If
MAXIMUS Federal agrees that the dismissal was appropriate, MAXIMUS Federal will affirm the
Medicare Health Plan’s dismissal. If MAXIMUS Federal finds that the Medicare Health Plan’s
dismissal was NOT appropriate (or new information has been discovered since the time of the
Medicare Health Plan’s dismissal making the appeal request valid), MAXIMUS Federal will
overturn the Medicare Health Plan’s dismissal and advise the Medicare Health Plan that it needs to
perform a substantive reconsideration.
8.3.1 FACTORS THAT MAY RESULT IN AN OVERTURN OF A PLAN’S
DECISION TO DISMISS
· The appellant has shown good cause for filing their appeal outside of the 60-day appeal
window and the reason for the Medicare Health Plan’s dismissal is untimely filing of the
appeal.
· The Medicare Health Plan has not provided proof that it made attempts to secure
representative or Waiver of Liability documentation in accordance with Chapter 13 of the
Medicare Managed Care Manual.
If MAXIMUS Federal decides that the Medicare Health Plan’s dismissal should be
overturned, then the Medicare Health Plan is responsible for rendering a full, substantive
reconsideration of the issue at appeal. If, at the end of this reconsideration, the Medicare Health Plan
denies coverage of or payment for the item or service in dispute, in whole or in part, the Medicare
Health Plan should follow the appropriate steps for forwarding the case for independent review to
MAXIMUS Federal as per the instructions in this Manual.
Please note: when Medicare Health Plans send these cases to MAXIMUS Federal for
substantive reconsideration review, Medicare Health Plans should include in the case file a copy of
the MAXIMUS Federal overturn decision from the dismissal review. The date of the overturn
decision will serve as the date of the reconsideration request for purposes of completing the
Reconsideration Background Data Form.
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8.4 DISMISSAL CASE FILE DOCUMENTATION
For dismissal review case files being submitted by the Medicare Health Plan at MAXIMUS
Federal request, Medicare Health Plans should send an abbreviated case file. The case file should
include:
· The Medicare Managed Care Dismissal Case File Data Form
· A Dismissal Case File Narrative
· The organization determination documents
· The appeal request documents
· A copy of the Notice of Dismissal of Appeal Request
· Documentation of attempts made by the Medicare Health Plan to have the appealing party
correct any appeal request deficiency
8.4.1 THE MEDICARE MANAGED CARE DISMISSAL CASE FILE DATA
FORM
Every request from MAXIMUS Federal to a Medicare Health Plan for a dismissal case file
needs to be accompanied by the Medicare Managed Care Dismissal Case File Data Form. While
similar to the Reconsideration Background Data Form, this form contains fewer and different data
elements. The Medicare Health Plan must designate a contact person on the Medicare Managed
Care Dismissal Case File Data Form. Medicare Health Plans must also include the MAXIMUS
Federal Appeal Number on this form. This Appeal Number will be provided to the Medicare Health
Plan on the faxed case file request form.
8.4.2 ACKNOWLEDGMENT LETTERS
MAXIMUS Federal will not issue acknowledgment letters to either the appellant or the
Medicare Health Plan regarding dismissal review requests.
8.5 TIMEFRAMES FOR MAXIMUS FEDERAL REVIEW
All dismissal review requests will be reviewed by MAXIMUS Federal in accordance with
the timeframes applicable to the priority of the appeal. This means that for expedited dismissal
reviews, MAXIMUS Federal will render its dismissal decision within 72 hours of receipt of the case
file from the Medicare Health Plan. For standard service (pre-service) dismissal review requests,
decisions will be made within 30 days of receipt of the case file from the Medicare Health Plan. For
standard service Part B drug dismissal review requests, decisions will be made within 7 days of
receipt of the case file from the Medicare Health Plan. For standard claim (payment) dismissal
review requests, decisions will be made within 60 days of receipt of the case file from the Medicare
Health Plan. If MAXIMUS Federal needs to request additional information from the Medicare
Health Plan in order to process the dismissal review, an extension of 14 days is permitted for
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expedited and standard service (pre-service) cases. No extensions are permitted for standard service
Part B drug and standard claim (payment) dismissal reviews.
8.6 DISMISSAL REVIEW DECISIONS ARE BINDING
As per CMS guidance, MAXIMUS Federal decisions regarding dismissal reviews are
binding. No parties to the dismissal will have further appeal rights of the dismissal decision.
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9. RECONSIDERATION DATA
MAXIMUS Federal extracts numerous data elements from submitted reconsideration case
files and provides reports to CMS based on the collected data. This Section discusses the related
data systems and how the collected information is used within the reports.
The topics addressed are:
9.1 Medicare Appeals System
9.2 Medicare Health Plan Monitoring Reports
9.3 Using the MAXIMUS Federal Website to Track Timeliness and Effectuation
9.1 MEDICARE APPEALS SYSTEM
MAXIMUS Federal utilizes the Medicare Appeal System (MAS) to support administration
of the reconsideration process. Data is obtained and entered into MAS from the following sources:
· CMS data systems, which provide enrollee and Medicare Health Plan identifying
information;
· Reconsideration Background Data Forms, from which certain data fields completed by the
Medicare Health Plans are entered, as given, to MAS;
· Adjudicator abstraction of information from other reconsideration case file documents.
In addition to providing data to MAXIMUS Federal for general program administration,
MAS data is relevant to Medicare Health Plans in the following ways:
· CMS obtains reports, based upon MAS data, to monitor certain aspects of Medicare Health
Plan compliance with appeal requirements.
· MAXIMUS Federal publishes Reconsideration Statistical Reports on the Project web site
www.medicareapppeal.com.
9.2 MEDICARE HEALTH PLAN MONITORING REPORTS
MAXIMUS Federal reports information to CMS related to:
· Timeliness of Medicare Health Plan organization determination and reconsideration
determination
· Medicare Health Plan effectuation of IRE, ALJ, or Medicare Appeals Council overturned
reconsideration determinations
It is important to note that MAXIMUS Federal provides the above reports to CMS Central
and Regional Offices to advise those offices of potential non-compliance. CMS personnel
determine how such reports should be used in discharge of their Medicare Health Plan monitoring
function. Typically, CMS personnel will contact the Medicare Health Plan if a significant issue (for
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example, outlier) or pattern appears to exist, and will provide the Medicare Health Plan the
opportunity to research the case(s) more thoroughly.
However, as will be explained below, the source of the reported compliance data is
primarily the Medicare Health Plan itself—specifically entries made to the Reconsideration
Background Data Form by the Medicare Health Plan. It is vital that the Medicare Health Plan
carefully and accurately complete the form.
Proper Use of CMS Prescribed Adverse Determination Notices
MAXIMUS Federal Adjudicators review the case file and ascertain which notice, if any, is
contained. The type of notice is compared against the type required for the given appeal. The format
and content of the Notice is also compared against related CMS requirements.
Timeliness of Medicare Health Plan - Organization Determination and Reconsideration
The Reconsideration Background Data Form (See Appendix) requires the Medicare Health
Plan to:
· Classify the case by priority (expedited, standard service, standard service Part B drug,
standard claim)
· Enter "date of receipt" and "date of completion" of the organization determination and
Medicare Health Plan reconsideration
· Enter requests for expedited processing and related Medicare Health Plan decision
· Indicate if a 14-day extension was taken "in the enrollee's interest" (this extension is not
applicable to standard claim and standard service Part B drug appeals).
This data is used to calculate the time interval within which the organization determination
and reconsideration should occur, and compares this interval with the actual timeliness reported by
the Medicare Health Plan. A variety of reports that measure Medicare Health Plan timeliness are
submitted to CMS using these calculations. This set of reports relies upon the information exactly as
given by the Medicare Health Plan on the Reconsideration Background Data Form. Consequently,
Medicare Health Plan errors or omissions on this form will result in reporting of either missing data
or cases outside of timeframe compliance.
In addition, the MAXIMUS Federal Adjudicators compare the contents of the case file (for
example, notices and correspondence) to the data reported by the Medicare Health Plan on the
Reconsideration Background Data Form. If the Adjudicator determines that an error or omission
exists on the Reconsideration Background Data Form, this error or omission is, if possible,
corrected and reported separately. MAXIMUS Federal uses this information to report
"discrepancies" with respect to Medicare Health Plan reported timeliness to CMS.
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Timeliness of Effectuation Compliance
Using the Medicare Health Plan's report of effectuation to MAXIMUS Federal, we report to
CMS listings of cases without compliance notice and statistics on effectuation compliance.
9.3 USING THE MAXIMUS FEDERAL WEBSITE TO TRACK TIMELINESS AND
EFFECTUATION
MAXIMUS Federal is responsible for providing CMS with data for certain STAR rating
measures and for data in support of Regional Office (RO) Medicare Health Plan oversight activity.
Specifically, MAXIMUS Federal provides CMS with timeliness data for STAR metric C32 and
with overturn rates for metric C33. In addition, MAXIMUS Federal provides reports indicating
cases where MAXIMUS Federal has not been notified of overturned cases requiring compliance
effectuation.
In order to allow Medicare Health Plans to proactively monitor the cases that they have sent
to MAXIMUS Federal for processing, we have developed a website that allows Medicare Health
Plans to access timeliness and compliance data in real time: www.medicareappeal.com. This
website is updated daily and is current as of the close of business on the previous business day.
It is important that Medicare Health Plans continuously review their underlying measure
data that are the basis for the Part C Star Ratings. CMS expects Medicare Health Plans to routinely
monitor these data. Medicare Health Plans that notice discrepancies or have questions about the data
should bring these issues to the attention of MAXIMUS Federal as they arise. Medicare Health
Plans are encouraged to submit any questions they may have about the data to the email box linked
under the ‘Contact Us’ tab on the MAXIMUS Federal Part C appeals website or on the Contact
Information page in the Medicare Advantage Reconsideration Process Manual. Medicare Health
Plans that wait to raise issues with their data until CMS’ plan preview periods may find there is
inadequate time to investigate and resolve them within the production schedule for the release of the
Star Ratings. Any issues or problems should be raised well in advance of CMS’ plan preview
periods.
The following sections will review the resources that are available on the website so that
Medicare Health Plans can use the information throughout the year to monitor their own cases as
well as report any discrepancies well in advance of STAR data being reported.
9.3.1 PLAN TIMELINESS DATA
Plans can access timeliness data from the www.medicareappeal.com website by hovering
over the “Health Plans” tab at the top of the main interface page of the site. The drop-down menu
that appears there will have a selection option called “Search for Your Appeals Case.” Once
selected, this tab gives Medicare Health Plans the option of searching for data for a particular
contract number or case number. It also allows Medicare Health Plans to limit the search by either
the date that MAXIMUS Federal receives the case or the date that MAXIMUS Federal renders its
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decision. Once the limiting information is entered into this search box, a list of results data will
appear.
MAXIMUS Federal provides two different data elements to CMS to calculate timeliness.
As mentioned above, after performing a search, a list of results data will appear. These case
search results are divided into columns. The data columns used to report timeliness data to CMS are
columns 2 (IRE Request Received Date), column 4 (Plan Reported Recon Receipt Date), and
column 5 (IRE Corrected Recon Receipt Date). Column 2 represents the date that MAXIMUS
Federal receives the case file from the Medicare Health Plan. Column 4 represents the date that the
Medicare Health Plan reports to MAXIMUS Federal on the Reconsideration Background Data
Form that they received the valid appeal request from the appellant. Column 5, if filled in, is the
date that, after going through the documentation in the case file, MAXIMUS Federal has
determined is the actual appeal start date. Timeliness is based on the number of days between
columns 2 and 4. If there is a date in column 5, then timeliness is based on the number of days
between columns 2 and 5.
For example, for retrospective (i.e., payment) cases, Medicare Health Plans have 60 days to
render their reconsiderations. In addition, for purposes of calculating timeliness, MAXIMUS
Federal allows 5 days for mailing of standard pre-service and retrospective cases (see Section 5.2).
Therefore, if columns 2 and 4 are more than 65 days apart, the case will be considered late. If there
is a date in column 5, the case will be considered late if there are more than 65 days between
columns 2 and 5.
The calculation works in the same manner for expedited, standard pre-service cases, and
standard Part B drug cases, although with different timeframes allowed. For standard pre-service
cases, Medicare Health Plans have 30 days to render their reconsideration. Once again, MAXIMUS
Federal allows 5 days for mailing. Therefore, standard pre-service cases received more than 35 days
beyond the date in column 4 will be considered late. Of course, for standard pre-service cases,
extensions are allowed for Medicare Health Plans to gather additional information. If the Medicare
Health Plan has alerted MAXIMUS Federal via the Reconsideration Background Data Form that
they have taken an extension, it will be noted in column 6. A ‘Y’ finding in this column will allow
for an additional 14 days for standard pre-service cases. Therefore, for standard pre-service cases
where there was an extension taken, there should be no more than 49 days between columns 2 and
4.
For expedited cases, the standard timeframe is 72 hours (or 3 days). However, due to the
nature of expedited appeals, only one business day is allowed for mailing. Medicare Health Plans
are expected to submit expedited cases to MAXIMUS Federal via overnight mail or the QIC
Appeals Portal. Because Sundays and Federal holidays are not considered business days, for appeals
where the mailing day would fall on a Sunday or a Federal holiday, one extra day is permitted for
those cases to arrive. The same caveat for extensions for standard pre-service cases applies to
expedited cases as well.
Effective January 1, 2020, for standard Part B drug cases, Medicare Health Plans have 7
days to render their reconsideration. Due to the nature of these appeals, only one business day is
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allowed for mailing. Medicare Health Plans are expected to submit standard Part B drug cases to
MAXIMUS Federal via overnight mail or the QIC Appeals Portal. Because Sundays and Federal
holidays are not considered business days, for appeals where the mailing day would fall on a
Sunday or a Federal holiday, one extra day is permitted for those cases to arrive.
In 2019, MAXIMUS added a column to the website to represent plan timeliness at CMS’
request. All cases found to be timely using the above described formula, will be indicated as “Yes”
timely. All cases found to be untimely will be indicated as “No”.
9.3.2 PLAN EFFECTUATION DATA
The www.medicareappeal.com website can also be used by Medicare Health Plans to
monitor effectuation and compliance. The method of performing a search for this data on the
website is very similar to the method used for seeing timeliness data. From the main page of the
website, Medicare Health Plans can hover over the “Health Plans” tab at the top of the page. A drop
down menu will appear, with a selection entitled “Search Effectuation Data.” This selection allows
Medicare Health Plans to monitor which of their cases have been overturned or partially overturned
and determine if MAXIMUS Federal has received Medicare Health Plan compliance information.
As with timeliness data, Medicare Health Plans can limit the search by contract number, case
number, or date. Once search criteria are entered, a results data list will appear.
This data listing advises Medicare Health Plans what the MAXIMUS Federal decision was
and if notice of their compliance with that decision has been received. Medicare Health Plans may
wish to check this data daily if they are waiting to see if MAXIMUS Federal has received
compliance information. In addition, Medicare Health Plans can monitor those cases where
MAXIMUS Federal has not noted a compliance was received. MAXIMUS strongly encourages
Medicare Health Plans to review effectuation data on our website and address any outdated
effectuations.
9.3.3 DATA DISCREPANCIES
If a Medicare Health Plan notices that there is no compliance data entered for a case where
they have sent compliance information to MAXIMUS Federal, or that timeliness data listed on the
website appears to be inaccurate, MAXIMUS Federal can investigate that discrepancy. With either
the timeliness or effectuation data, if a Medicare Health Plan has a question about a data element or
wants to report a discrepancy, they can send an email to the email box linked under the “Contact
Us” tab in the upper right hand corner of the website. This email box is continuously monitored and
questions are answered promptly.
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Appendix A- Model Appellant Dismissal Form
