42 C.F.R. §§ 405.940–405.958

§405.940. Right to a redetermination.

42 C.F.R. § 405.940

A person or entity that may be a party to a redetermination in accordance with § 405.906(b) and that is dissatisfied with an initial determination may request a redetermination by a contractor in accordance with § 405.940 through § 405.958, regardless of the amount in controversy.

Notes, amendments, and revision history

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

§405.942. Time frame for filing a request for a redetermination.

42 C.F.R. § 405.942

(a)

Time frame for filing a request. Except as provided in paragraph (b) of this section, any request for redetermination must be filed within 120 calendar days from the date a party receives the notice of the initial determination.

(1)

For purposes of this section, the date of receipt of the initial determination will be presumed to be 5 calendar days after the date of the notice of initial determination, unless there is evidence to the contrary.

(2)

The request is considered as filed on the date it is received by the contractor.

(b)

Extending the time frame for filing a request. General rule. If the 120 calendar day period in which to file a request for a redetermination has expired and a party shows good cause, the contractor may extend the time frame for filing a request for redetermination.

(1)

How to request an extension. A party may file a request for an extension of time for filing a request for a redetermination with the contractor. The party should include any evidence supporting the request for extension. The request for redetermination extension must—

(i)

Be in writing;

(ii)

State why the request for redetermination was not filed within the required time frame; and

(iii)

Meet the requirements of § 405.944.

(2)

How the contractor determines if good cause exists. In determining if a party has good cause for missing a deadline to request a redetermination, the contractor considers—

(i)

The circumstances that kept the party from making the request on time;

(ii)

If the contractor's action(s) misled the party; and

(iii)

If the party had or has any physical, mental, educational, or linguistic limitations, including any lack of facility with the English language, that prevented the party from filing a timely request or from understanding or knowing about the need to file a timely request.

(3)

Examples of good cause. Examples of circumstances when good cause may be found to exist include, but are not limited to, the following situations:

(i)

The party was prevented by serious illness from contacting the contractor in person, in writing, or through a friend, relative, or other person; or

(ii)

The party had a death or serious illness in his or her immediate family; or

(iii)

Important records of the party were destroyed or damaged by fire or other accidental cause; or

(iv)

The contractor gave the party incorrect or incomplete information about when and how to request a redetermination; or

(v)

The party did not receive notice of the determination or decision; or

(vi)

The party sent the request to a Government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009]

§405.944. Place and method of filing a request for a redetermination.

42 C.F.R. § 405.944

(a)

Filing location. The request for redetermination must be filed with the contractor indicated on the notice of initial determination.

(b)

Content of redetermination request. The request for redetermination must be in writing and should be made on a standard CMS form. A written request that is not made on a standard CMS form is accepted if it contains the same required elements as follows:

(1)

The beneficiary's name;

(2)

The Medicare number;

(3)

Specific service(s) and/or item(s) for which the redetermination is being requested and the specific date(s) of the service;

(4)

The name of the party or the representative of the party.

(c)

Requests for redetermination by more than one party. If more than one party timely files a request for redetermination on the same claim before a redetermination is made on the first timely filed request, the contractor must consolidate the separate requests into one proceeding and issue one redetermination.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 84 FR 19869, May 7, 2019]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 84 FR 19869, May 7, 2019]

§405.946. Evidence to be submitted with the redetermination request.

42 C.F.R. § 405.946

(a)

Evidence submitted with the request. When filing the request for redetermination, a party must explain why it disagrees with the contractor's determination and should include any evidence that the party believes should be considered by the contractor in making its redetermination.

(b)

Evidence submitted after the request. When a party submits additional evidence after filing the request for redetermination, the contractor's 60 calendar day decision-making time frame is automatically extended for up to 14 calendar days for each submission.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005; 74 FR 65333, Dec. 9, 2009]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005; 74 FR 65333, Dec. 9, 2009]

§405.947. Notice to the beneficiary of applicable plan's request for a redetermination.

42 C.F.R. § 405.947

(a)

A CMS contractor must send notice of the applicable plan's appeal to the beneficiary.

(b)

Issuance and content of the notice must comply with CMS instructions.

Notes, amendments, and revision history

Amendments

[80 FR 10618, Feb. 27, 2015]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[80 FR 10618, Feb. 27, 2015]

§405.948. Conduct of a redetermination.

42 C.F.R. § 405.948

A redetermination consists of an independent review of an initial determination. In conducting a redetermination, the contractor reviews the evidence and findings upon which the initial determination was based, and any additional evidence the parties submit or the contractor obtains on its own. An individual who was not involved in making the initial determination must make a redetermination. The contractor may raise and develop new issues that are relevant to the claims in the particular case.

Notes, amendments, and revision history

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

§405.950. Time frame for making a redetermination.

42 C.F.R. § 405.950

(a)

General rule. The contractor mails, or otherwise transmits, written notice of the redetermination or dismissal to the parties to the redetermination at their last known addresses within 60 calendar days of the date the contractor receives a timely filed request for redetermination.

(b)

Exceptions.

(1)

If a contractor grants an appellant's request for an extension of the 120 calendar day filing deadline made in accordance with § 405.942(b), the 60 calendar day decision-making time frame begins on the date the contractor receives the late-filed request for redetermination, or when the request for an extension is granted, whichever is later.

(2)

If a contractor receives from multiple parties timely requests for redetermination of a claim determination, consistent with § 405.944(c), the contractor must issue a redetermination or dismissal within 60 calendar days of the latest filed request.

(3)

If a party submits additional evidence after the request for redetermination is filed, the contractor's 60 calendar day decision-making time frame is extended for up to 14 calendar days for each submission, consistent with § 405.946(b).

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005; 74 FR 65333, Dec. 9, 2009]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005; 74 FR 65333, Dec. 9, 2009]

§405.952. Withdrawal or dismissal of a request for a redetermination.

42 C.F.R. § 405.952

(a)

Withdrawing a request. A party that files a request for redetermination may withdraw its request by filing a written and signed request for withdrawal. The request for withdrawal must contain a clear statement that the appellant is withdrawing the request for a redetermination and does not intend to proceed further with the appeal. The request must be received in the contractor's mailroom before a redetermination is issued. The appeal will proceed with respect to any other parties that have filed a timely request for redetermination.

(b)

Dismissing a request. A contractor dismisses a redetermination request, either entirely or as to any stated issue, under any of the following circumstances:

(1)

When the person or entity requesting a redetermination is not a proper party under § 405.906(b) or does not otherwise have a right to a redetermination under section 1869(a) of the Act;

(2)

When the contractor determines the party failed to make out a valid request for redetermination that substantially complies with § 405.944;

(3)

When the party fails to file the redetermination request within the proper filing time frame in accordance with § 405.942;

(4)

When a beneficiary or the beneficiary's representative files a request for redetermination, but the beneficiary dies while the request is pending, and all of the following criteria apply:

(i)

The beneficiary's surviving spouse or estate has no remaining financial interest in the case. In deciding this issue, the contractor considers if the surviving spouse or estate remains liable for the services for which payment was denied or a Medicare contractor held the beneficiary liable for subsequent similar services under the limitation on liability provisions based on the denial of payment for services at issue;

(ii)

No other individual or entity with a financial interest in the case wishes to pursue the appeal; and

(iii)

No other party filed a valid and timely redetermination request under §§ 405.942 and 405.944;

(5)

When a party filing the redetermination request submits a timely written request for withdrawal with the contractor; or

(6)

When the contractor has not issued an initial determination on the claim or the matter for which a redetermination is sought.

(c)

Notice of dismissal. A contractor mails or otherwise transmits a written notice of the dismissal of the redetermination request to the parties at their last known addresses. The notice states that there is a right to request that the contractor vacate the dismissal action.

(d)

Vacating a dismissal. If good and sufficient cause is established, a contractor may vacate its dismissal of a request for redetermination within 180 calendar days from the date of the notice of dismissal.

(e)

Effect of dismissal. The dismissal of a request for redetermination is binding unless it is modified or reversed by a QIC under § 405.974(b) or vacated under paragraph (d) of this section.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009; 84 FR 19870, May 7, 2019]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009; 84 FR 19870, May 7, 2019]

§405.954. Redetermination.

42 C.F.R. § 405.954

Upon the basis of the evidence of record, the contractor adjudicates the claim(s), and renders a redetermination affirming or reversing, in whole or in part, the initial determination in question.

Notes, amendments, and revision history

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

§405.956. Notice of a redetermination.

42 C.F.R. § 405.956

(a)

Notification to parties—

(1)

General rule. Written notice of a redetermination affirming, in whole or in part, the initial determination must be mailed or otherwise transmitted to all parties at their last known addresses in accordance with the time frames established in § 405.950. Written notice of a redetermination fully reversing the initial determination must be mailed or otherwise transmitted to the appellant in accordance with the time frames established in § 405.950. If the redetermination results in issuance of supplemental payment to a provider or supplier, the Medicare contractor must also issue an electronic or paper RA notice to the provider or supplier.

(2)

Overpayment cases involving multiple beneficiaries who have no liability. In an overpayment case involving multiple beneficiaries who have no liability, the contractor may issue a written notice only to the appellant.

(b)

Content of the notice for affirmations, in whole or in part. For decisions that are affirmations, in whole or in part, of the initial determination, the redetermination must be written in a manner calculated to be understood by a beneficiary, and contain—

(1)

A clear statement indicating the extent to which the redetermination is favorable or unfavorable;

(2)

A summary of the facts, including, as appropriate, a summary of the clinical or scientific evidence used in making the redetermination;

(3)

An explanation of how pertinent laws, regulations, coverage rules, and CMS policies apply to the facts of the case;

(4)

A summary of the rationale for the redetermination in clear, understandable language;

(5)

Notification to the parties of their right to a reconsideration and a description of the procedures that a party must follow in order to request a reconsideration, including the time frame within which a reconsideration must be requested;

(6)

A statement of any specific missing documentation that must be submitted with a request for a reconsideration, if applicable;

(7)

A statement that all evidence the appellant wishes to introduce during the claim appeals process should be submitted with the request for a reconsideration;

(8)

Notification that evidence not submitted to the QIC as indicated in paragraph (b)(6) of this section, is not considered at the OMHA level or further appeal, unless the appellant demonstrates good cause as to why that evidence was not provided previously; and

(9)

The procedures for obtaining additional information concerning the redetermination, such as specific provisions of the policy, manual, or regulation used in making the redetermination.

(10)

Any other requirements specified by CMS.

(c)

Content of the notice for a full reversal. For decisions that are full reversals of the initial determination, the redetermination must be in writing and contain—

(1)

A clear statement indicating that the redetermination is wholly favorable;

(2)

Any other requirements specified by CMS.

(d)

Exception for beneficiary appeal requests.

(1)

The notice must inform beneficiary appellants that the requirements of paragraph (b)(8) of this section are not applicable for purposes of beneficiary appeals.

(2)

This exception does not apply for appeal requests from beneficiaries who are represented by providers or suppliers.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5107, Jan. 17, 2017]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5107, Jan. 17, 2017]

§405.958. Effect of a redetermination.

42 C.F.R. § 405.958

In accordance with section 1869(a)(3)(D) of the Act, once a redetermination is issued, it becomes part of the initial determination. The redetermination is binding upon all parties unless—

(a)

A reconsideration is completed in accordance with § 405.960 through § 405.978; or

(b)

The redetermination is revised as a result of a reopening in accordance with § 405.980.

Notes, amendments, and revision history

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009]

Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

Amendments

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65333, Dec. 9, 2009]