The Medicare, Medicaid and State Children's Health Insurance Program [SCHIP] Benefits Improvement and Protection Act of 2000 (BIPA) impacted the Medicare claim appeals process. As a result of BIPA, Section 1869 (c) of the Social Security Act (the Act), was also amended. These Acts and their impacts in turn required changes to the 42 Code of Federal Regulations in relationship to the appeals process. CMS recently released a memorandum focused on the revisions and changes made in order to meet 42 Code of Federal Regulations (CFR), Parts 401 and 405, Medicare program requirements. This newly released memorandum addresses changes made to comply with the changes detailed in the Medicare Claims Appeals Procedures; Interim Final Rule (IFR). This lengthy memorandum contained multiple updates, including glossary additions and revisions, as well as revisions to the existing appeals process.

Changes also include updated information on the minimum controversy amounts for appeal at Level 2 and Level 5, how to handle misrouted appeals and paid claims appeals. In addition, it addresses when the beneficiary can request the Medicare Appeals Council to review a case, in the event that the beneficiary is dissatisfied with the decision of the Administrative Law Judge [ALJ]. If this is the case, the beneficiary can now ask that the case undergo a Departmental Appeals Board (DAB) Review. The Medicare Appeals Council begins anew with an independent and thorough evaluation and review of the ALJ decision. This council has several courses of action that can be taken and include adopting, modifying or reversing the ALJ’s decision, or remanding the case to an ALJ for further proceedings. In the case of an ALJ’s dismissal order, the Appeals Council may deny review or vacate the dismissal and remand/return the case to an ALJ for additional study, evaluation and decision.

The memorandum further addresses changes relative to case reopenings, individuals and/or parties having the right to appeal and beneficiaries, and provides a table with time frames and established amounts that must be in controversy. This table provides information at each level, i.e., Level 1 Redetermination, Level 2 Reconsideration, Level 3 Administrative Law Judge Hearing, Level 4 Departmental Appeals Board (DAB) Review/Appeals Council and Level 5 Federal Court Review.

Other key sections with revisions address the required Elements for Written Request, in lieu of using the CMS-1696 form, time frames for Redetermination Decision mailings/notifications, whether unfavorable, partially favorable or fully favorable and there are sample letters provided.

The complete Transmittal 1762, SUBJECT: Appeals Revisions, Change Request 6377 released by Department of Health & Human Services (DHHS) and Centers for Medicare & Medicaid Services (CMS) on July 2, 2009 is available for review and downloading at
http://www.cms.hhs.gov/transmittals/downloads/R1762CP.pdf.