OM_AdQIC_ Eligibility Contractor Activities - SOW.pdf

Appendix D- Eligibility Activities

Optional Appendix D:

Scope of Work for Eligibility Contractor Activities

A. Background and Overview:

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule titled Medicare Program:

Appeal Rights for Certain Changes in Patient Status-CMS-4204-P on December 27, 2023[1]. This regulation sets forth new appeals procedures to implement the court order in Alexander v. Azar, 613 F.

Supp. 3d 559 (D. Conn. 2020)), aff’d sub nom., Barrows v. Becerra, 24 F.4th 116 (2d Cir. 2022). Note:

CMS is currently working towards issuing the final rule. To the extent there are revisions in the final rule that have a material impact on this scope of work, CMS shall work to formally amend and revise this scope of work and any applicable requirements.

In the court order, the Department of Health and Human Services (HHS) was directed to, “. . . permit all members of the modified class to appeal the denial of Part A coverage” and to establish appeal procedures for certain beneficiaries in Original Medicare who are initially admitted to a hospital as an inpatient by a physician but whose status during their stay is changed to outpatient receiving observation services2 by the hospital, thereby effectively denying Part A coverage for their hospital stay. In some cases, the denial of Part A coverage of the hospital stay also affects coverage of a beneficiary’s post-hospital extended care services furnished in a skilled nursing facility (SNF). The court order requires HHS to establish new retrospective appeal procedures that will enable eligible beneficiaries to appeal the denial of Part A coverage for hospital stays on or after January 1, 2009. Eligible parties will have 365 calendar days3 from the implementation date specified in the final regulation CMS-4204-F, to submit a request for retrospective appeal to the eligibility contractor.

B. Purpose The purpose of Appendix F and the related activities as defined below is to support HHS, and more specifically, the CMS in making eligibility determinations for retrospective appeals under this new appeals process. The contractor for this effort shall be known as the “Eligibility Contractor (EC).” The EC shall serve as a single point of contact for incoming retrospective appeal requests submitted by beneficiaries (or their appointed or authorized representatives), or, as applicable, the successors filing on behalf of a deceased beneficiary, under proposed 42 Code of Federal Regulations (CFR) 405.932.

The EC shall receive appeal requests under this new appeal process and shall determine the validity of the request and whether the request is filed by (or on behalf of) an eligible party. At a minimum, the contractor shall:

1. Establish a mailing address (such as a Post Office box), courier address, and secure facsimile to receive appeal requests. At the contractor’s discretion, the EC may also offer a secure electronic submission process.

2. Review the appeal request and determine if the request for appeal is valid on its face (i.e., the request included the required elements and timely). If the request does not contain all required elements or was submitted untimely, the EC shall contact the beneficiary (or the representative) and request that

1 https://www.federalregister.gov/documents/2023/12/27/2023-28152/medicare-program-appeal-rights-for-certain-changes-in-patient-status 2 Meaning the hospital changed the patient’s classification from an inpatient to an outpatient and the patient received observation services following the change in classification. See proposed 42 CFR 405.931(h).

3 Since the 365-calendar day deadline to file ends on a federal holiday (January 1, 2026), the deadline is extended to the next day which is not a federal holiday (January 2, 2026).

https://www.federalregister.gov/documents/2023/12/27/2023-28152/medicare-program-appeal-rights-for-certain-changes-in-patient-status https://www.federalregister.gov/documents/2023/12/27/2023-28152/medicare-program-appeal-rights-for-certain-changes-in-patient-status they provide the information needed to make the appeal valid and/or to provide good cause for an untimely filed appeal.

3. As described below in Task 4, for a request that includes all required elements and is timely (either on initial submission or after corrections), the EC shall review the appeal request and determine if the submission contains all information necessary to make an eligibility determination. The EC shall also issue a written acknowledgement letter to the beneficiary (or their representative), confirming receipt of the request, within 21 calendar days of receipt of the valid request. The acknowledgement letter shall identify and notify the beneficiary (or their representative) whether additional documentation is needed from the beneficiary (or their representative), and if so, if it will be requested from the Medicare Administrative Contractor (MAC), or the provider on the beneficiary’s (or their representative’s) behalf, and the related impact to the processing time for the eligibility determination.

4. If the EC determines that the appeal request is missing information needed to make an eligibility determination, the EC shall coordinate with the Part A MAC that currently has jurisdiction over Part A claims from the relevant hospital to have the MAC research claims data to support the eligibility determination and potentially, to request the MAC solicit documentation from the related hospital or SNF to support the EC’s ability to render an eligibility determination (see Task 4 below).

5. As described in Task 6 below, the EC shall determine whether the individual submitting the request (or the individual for whom a request is submitted, in the case of a request filed by a representative) meets the definition of an eligible party and is, thus, entitled to an appeal.

o The EC shall issue a notice to either deny or approve each eligibility appeal request received and notify the individual (or their representative) of the determination.

o For those requests that are denied (that is, the beneficiary does not meet the eligibility requirements set forth in the regulation and is not eligible for an appeal, or does not otherwise file a valid request), the individual filing the request (or their representative) shall have an opportunity to correct any errors and/or demonstrate why the appeal request should be approved. This process, known as a request for review is detailed below in Task 6.

o For appeal requests that are approved (that is, the request is valid and the beneficiary satisfies the requirements to be an eligible party), the EC shall close the related appeal in the Medicare Appeals System (MAS) within 5 calendar days, as detailed in Task 8 below, so that the related appeal can be timely promoted to the processing contractor (the respective MAC) to conduct the first level appeal.

6. In accordance with Task 8, the EC shall populate MAS with the appeal and all documentation submitted with the request and continuously update the system throughout the eligibility determination (including uploading of any documentation, notices issued, eligibility decision letters, etc.).

Additional details regarding the role of the EC and the specific activities required are identified below.

II. Requirements

The following is a minimum specification of the CMS security policies that must be maintained:

Eligibility Contractor Notes

CMS Rules of Behavior Form To be reviewed and updated, as applicable by the EC individuals who will be accessing the EC network remotely prior to receiving a CMS User ID.

CMS Interconnection Security Agreement

To be reviewed and updated, as applicable by the EC as an Organization 15 days after the date of this contract modification

CMS Data Use Agreement To be reviewed and updated, as applicable by the EC as an Organization 30 days after the date of this contract modification.

Security Test of the EC infrastructure Will occur 60 days after date of award, at CMS discretion, or to align with scheduled Authority to Operate (ATO) and Security Control Assessment or Adaptive Control Testing (ACT) Schedule as defined by the System’s Information System Security Officer (ISSO)

CMS Acceptable Risk Safeguards

(ARS)

CMS information technology (IT) security policy to enforce FISMA4 compliance for all IT systems.

CMS Business Partner System Security Manual (BPSSM)

CMS IT security policy for business partners who utilize CMS data and connect with CMS systems.

Note: In accordance with the BPPSM, the EC shall undergo a security audit and obtain an ATO within 6 months of contract modification, as applicable.

A. Phases:

The periods of performance (POP) for Appendix F are as follows:

• Implementation Activities: September 30, 2024 – December 31, 2024

• Operational Period for Optional Appendix F: January 1, 2025 – December 31, 2025

• Renewal Period I for Optional Appendix F: January 1, 2026 – September 13, 2026

• Ongoing as Good Cause Allows or until directed by CMS to cease EC related tasks.

A.1.Transition In/Preparation for Operational Activities:

The transition in/preparation for operational phase activities shall begin on September 30, 2024, and shall conclude no later than December 31, 2024. The EC shall ensure that the following actions, at a minimum, are accomplished during this phase:

• Procure necessary facilities (if applicable) and hiring/training additional staff for this effort.

• Review existing CMSnet connectivity to determine if changes are required.

• Establish new MAS access, as applicable, in addition to building out connectivity to new MAS

Webservices for EC, and test MAS and other CMS system connectivity and web service connectivity to ensure capabilities to populate MAS with the eligibility appeals information and documentation and participate as needed/required with the MAS maintainer on MAS system development.

• Modify existing Joint Operating Agreements (JOAs) with the Part A MACs, as applicable, to support effective communications related to the tasks under this directive.

4 Federal Information Security Management Act of 2002 (P. L. 107-347)

• Work collaboratively with CMS to review and finalize letter templates and forms (created by CMS and/or the EC) in support of this process, including but not limited to: EC acknowledgement letter(s), Eligibility Research Form for the MAC, an approval notice for a valid and eligible appeal, a denial notice for an invalid or ineligible appeal, a decision notice that either affirms or reverses the prior denial of the request for appeal, and a dismissal notice for untimely filed requests for review of a denial notice. In addition, the EC may also be tasked to support CMS in creating, updating, or revising FAQs for 1-800 Medicare in support of this process.

B. Specific Tasks to be Performed under Appendix F

Task 1: Transition In Meeting(s)/Kickoff Meetings Kick Off Meeting with CMS:

In preparing to implement SOW requirements, the EC shall arrange an initial meeting/kick-off conference with CMS. This meeting shall be held no later than 7 calendar days after the contract modification and shall be held via teleconference or online medium compatible with CMS computer systems. Prior to this meeting, the EC shall provide CMS with information regarding the hard copy mailing address (postal and courier information), facsimile number, as applicable, the electronic delivery information and/or other relevant information as to where eligibility requests or supporting documentation shall be submitted during the operational phase.

Following the meeting, the EC shall be responsible for providing meeting minutes to the Contracting Officer’s Representative (COR) related to the initial/kick off conference with CMS. These minutes shall be submitted to the COR via email within three (3) business days following the meeting.

Kick Off and Transition Meeting(s) with the Part A MACs:

The EC also shall have an initial meeting/kick off conference call with the Part A MACs to provide an overview of the coordination required for this effort and the anticipated communications. This meeting shall occur on November 14, 2024, at 2:00 pm EST or as otherwise directed by CMS and shall be held via teleconference or online medium compatible with CMS computer systems. At this initial meeting, the EC shall work with the Part A MACs and provide, at a minimum, the following information:

• A list of workgroup members, including roles; and POCs from each MAC organization/jurisdiction as well as sharing EC contacts with the applicable MACs.

• An overview of the anticipated process for conducting the eligibility determination, planned communications with the Part A MACs regarding requests for additional information to determine the eligibility (both claims information and documentation requests from hospitals and SNFs, as applicable) and other information to support successful implementation and operations related to this effort.

• Sharing of any proposed email distribution lists.

In addition, the EC shall schedule and lead follow up meetings with the Part A MACs, as required, to ensure:

• Operational readiness for soliciting additional information from the MACs to determine eligibility (i.e., request review of claims data, as needed, or requests for the MACs to solicit documentation from the hospital and/or SNF, on the beneficiary’s (or their representative’s) behalf, to support the eligibility determination).

• Operational readiness to support the transfer of eligible appeals from the EC to the respective MACs, following the eligibility determination, for processing of the first level appeal. That is, the timeline in which the EC will upload and close valid and eligible appeals within MAS so that the case can be automatically promoted to the MAC for processing of the level 1 appeal.

The call dates, times, and frequency will be at a mutually agreeable time, as determined by the EC and the MACs. The EC shall include the respective COR for the EC, MAC CORs, and anyone else as designated by CMS (e.g., Business Function Leads) in these meetings.

The EC shall be responsible for providing draft of meeting minutes and deliverables to the COR for the initial kick off meeting and any follow up meetings (in both the transition period and during the operational period, as applicable) no later than three (3) business days following each meeting. Final meeting minutes and deliverables listings shall be provided to all participants within 3 business days of receipt of any comments from the COR.

Kick Off Meeting with 1-800 Medicare Contractor (if requested by CMS):

The EC also shall have an initial meeting/kick off conference call with the 1-800 Medicare contractor to provide an overview of the coordination required for this effort and the anticipated communications as it relates to beneficiary (or their representative) inquiries received by 1-800 Medicare related to eligibility appeal requests that have been submitted by the beneficiary (or their representative) to the EC and are either pending a decision or have been decided. This meeting shall occur no later than 15 calendar days after the effective date of the contract modification and shall be held via teleconference or online medium compatible with CMS computer systems. At this initial meeting, the EC shall work with the 1-800 Medicare contractor and provide, at a minimum, the following information:

• A list of workgroup members and roles.

• Email Distribution lists.

• An overview of the anticipated process for coordinating any beneficiary inquiries received by 1-

800 Medicare that relate to eligibility requests pending at the EC or that have been decided.

• A communication process by which the EC will securely support 1-800 Medicare in responding directly to these inquiries or by which 1-800 Medicare will provide the details of these inquiries to the EC for the EC to respond directly to the beneficiary (or their representative) with the requested status or other information regarding pending or closed appeal requests.

If needed, the EC shall schedule and lead follow up meetings with the 1-800 Medicare contractor to ensure all needed communication mechanisms are established and noted in the related JOA prior to the implementation date for this new appeal process. The call dates, times, and frequency will be at a mutually agreeable time, as determined by the EC and the 1-800 Medicare contractor. The EC shall include the respective COR for the EC, 1-800 Medicare contract COR, and anyone else as designated by CMS (e.g., Business Function Leads) in these meetings.

The EC shall be responsible for providing draft meeting minutes and deliverables to the COR for the initial kick off meeting and any follow up meetings (in both the transition period and during the operational period, as applicable) no later than three (3) business days following each meeting. Final meeting minutes and deliverables listings shall be provided to all participants within 3 business days of receipt of any comments from the COR.

Task 2: Joint Operating Agreements (JOAs) Update Existing JOAs with the Part A MACs The EC shall update the existing JOAs with the respective Part A MACs to outline, at a minimum but not limited to:

• The communication process for requesting MAC research of claims data on appeals received, as applicable to support the eligibility determination.

• The communication process for MACs requesting additional documentation from hospital and SNFs, as applicable, to support the eligibility determination.

• The timeframe for MACs to upload into the MAS the documentation received and notify to the EC that these actions have occurred (tbd if notification will be required or if this will happen systematically-CMS to update after requirements finalized).

• Communications when the eligibility determination has been made by the EC and the timeframe by which the EC will close the appeal in MAS so that it can be automatically promoted to the MAC for processing of the first level appeal, as applicable.

• In addition, the JOAs shall also be updated to include a communication process for situations in which a beneficiary directly appeals to the MAC rather than the EC.

The finalized JOA (or updates) between the EC and the Part A MACs shall be completed no later than 15 calendar days prior to the implementation date for this new appeal process (currently January 1, 2025).

Creating a New JOA with 1-800 Medicare Contractor (if requested by CMS) The EC shall also develop a draft JOA for use with the 1-800 Medicare contract in order to support communications related to beneficiary inquiries to 1-800 Medicare regarding requests pending at the EC or decided by the EC. CMS shall, at a minimum:

• Provide the point of contact names at 1-800 Medicare and the EC by which the entities shall communicate and collaborate with each other, in a secure manner, to address beneficiary inquiries to 1-800 Medicare related to pending or closed appeal requests submitted to the EC. Point of contact email address or distribution email box can be provided.

The draft JOA shall be provided to the EC and 1-800 Medicare CORs and the 1-800 Medicare contractor within 20 calendar days of completion of this contract modification. The final JOA shall be completed no later than 30 calendar days prior to the implementation date of this appeals process (currently January 1, 2025).

Task 3: Website The EC shall develop and go-live with a public facing tab/information on its existing public website regarding this new appeal process and the EC’s responsibilities related to this effort. This new information/tab on the existing website shall go live/be available to the public no later than 30 calendar days prior to the implementation start date (currently January 1, 2025).

The website information shall, at a minimum but not limited to:

• Describe (at high level) the new appeal process.

• Describe the timeframes by which beneficiaries must submit their requests to the EC.

• Post the appeal request form and provide a link to the form on the CMS website(s) (e.g., on

Medicare.gov (CMS to provide URL and the form during the implementation phase)) to assist beneficiaries in completing their appeal request.

• Information regarding the mailing address and other mechanisms for submission of the request and/or related documentation (e.g., facsimile number, secure communications, as applicable, etc.).

• FAQs as determined by the EC and CMS that may assist beneficiaries in submitting their appeal request or understanding the timeframe by which the EC will render a determination.

• An Eligibility Determination status look up tool. This look up tool shall provide and store no PHI or PII. All the case statuses the be queried by case number only and provide simple high level status including but not limited to 1) Received, 2) Under Review, 3) Decided, 4) No record. The EC may add more values if practical.

The COR shall provide additional information, upon completion of this modification/award, regarding what information needs to be included on the website. The EC shall provide the COR with a draft of its proposed website and related materials within 45 calendar days of completion of this contract modification. Following implementation, the EC shall update the website FAQs or other documentation, as needed, to clarify this process for beneficiaries and provide support. Any updates to the website shall be approved by the EC COR and shall go live on the public facing website within 7 calendar days of the EC COR’s approval.

Task 4: Receive Requests and Determine if they are Valid In accordance with proposed 42 CFR 405.932(a)(2), eligible parties shall have 365 calendar days from the implementation date specified in the HHS Final Rule (CMS-4204-F) (currently projected: January 1, 2025 – December 31, 2025) to submit a timely request to the EC for a retrospective appeal. The requests shall be submitted in writing. The EC shall establish a P.O. Box, courier address, a facsimile number, and if preferred (not required) offer a secure electronic mechanism for submission (e.g., secure email or secure portal) by which beneficiaries may submit the eligibility requests. Beneficiaries (or their representative) may submit the request using the following request form available at Medicare.gov (CMS to provide URL when the form is complete/publicly available) or if the form is not utilized the request must include the following required elements:

1. Beneficiary’s name

2. Medicare number

3. Name of the hospital and the date(s) of the hospitalization

4. Name of the Skilled Nursing Facility and the dates of stay (as applicable)

5. If the appeal includes SNF services not covered by Medicare and not paid by a third-party insurer

(such as a supplementary or secondary insurer), the written request must also include an attestation to the out-of-pocket payment(s) made by the beneficiary for such SNF services and must include documentation of payments made by the beneficiary (or a beneficiary’s family member) to the SNF for such services.

In addition to the above required elements, the written request may also include an explanation as to why the hospital admission satisfied the relevant criteria for Part A coverage and the service should have been covered under Part A hospital insurance benefit and not under the Part B supplementary medical insurance benefit.

Upon receipt of an appeal request, the EC shall first determine if the appeal request is valid on its face (includes the required elements and is received timely), (see proposed 42 CFR 405.932(b)).

When a beneficiary has an appointed representative, assisting the beneficiary with the request, the EC shall review and confirm a valid authorized appointment of representative form or other conforming instrument has been included with the eligibility request (see 42 CFR 405.902-405.910). See also QIC Manual, Chapter 3, Section 3.20 for additional guidance. Note: in accordance with 42 CFR 405.931(d)(1)(i), a provider of services who furnished items or services to a beneficiary whose claims are the subject of an appeal under the provisions of §§ 405.931 through 405.938 is prohibited from representing the beneficiary or eligible party in such appeal.

Actions After Receipt of Invalid Request (Missing Elements or Untimely):

Missing Required Elements: If the initial request does not include all the required elements, the EC shall notify the beneficiary (or their representative) in the acknowledgement letter (issued no later than 21 calendar days after receipt of the appeal request) regarding the elements that are missing to make the request valid. CMS will collaborate with the EC prior to the implementation date to develop an acknowledgement letter template for this scenario.

Untimely Filed Request: If the initial request was not submitted timely, the EC shall notify the beneficiary (or their representative) in the acknowledgement letter (issued no later than 21 calendar days after receipt of the appeal request) that good cause is needed to support the processing of the untimely request (see proposed 42 CFR 405.942(b)(2) and (3)). CMS will collaborate with the EC prior to the implementation date to develop an acknowledgement letter template for this scenario.

The related acknowledgement letter issued by the EC shall clearly articulate what information is needed to make the request valid or, as applicable, to clarify for the beneficiary (or their representative) that information is needed to support good cause for the untimely filing. Under either scenario, the acknowledgement letter shall notify the beneficiary (or their representative) that they have 14 calendar days from the date of receipt of the acknowledgment letter to cure the invalid request, and the way the beneficiary (or their representative) can provide this information to the EC (via mail, Courier, or secure facsimile). The date of receipt of the acknowledgement letter is presumed to be five (5) calendar days from the date of the letter unless there is evidence to the contrary.

If the beneficiary (or their representative) provides the requested information to make the appeal valid or, as applicable, provides good cause for the untimely filed request, the EC shall proceed with processing the request.

If the beneficiary (or their representative) fails to respond to the request for additional information to render the appeal valid or timely, the EC shall deny the request (see Task 6 for additional guidance).

Actions After Receipt of Valid Request (Includes Required Elements and Submitted Timely):

Upon receipt of a valid and timely request (including requests that are cured) the EC shall issue, within 21 calendar days of receipt of the valid and timely request, an acknowledgement letter to the beneficiary (or their representative) acknowledging receipt of the appeal request. CMS will collaborate with the EC prior to the implementation date to develop an acknowledgement letter template for the following scenarios related to valid requests:

1. For requests that comply with the content requirements for a valid appeal request (see 42 CFR

405.932(b)(1)) but based on the information provided with the request, the EC determines that the beneficiary does not meet the requirements for an eligible party (see 42 CFR 405.931(b)), the EC shall issue an eligibility determination/decision without further development for additional information or records. For example, but not limited to:

a. The beneficiary submits an appeal request for a hospitalization that occurred prior to January 1, 2009. This beneficiary would not meet the definition of an eligible party in 42 CFR 405.931(d) without requesting additional records or documentation.

b. The beneficiary submits an appeal request with a Medicare Summary Notice (MSN) that indicates a two-day hospital stay for inpatient services and submits an MSN for denied services along with proof of out-of-pocket payment for the SNF services. The beneficiary would not meet the definition of an eligibility party in 42 CFR 405.931(b) based on the lack of a three or more consecutive hospital stay and for not being reclassified by the hospital from an inpatient to an outpatient receiving observation services. The EC may issue a denial under 42 CFR 405.931(d).

In the above circumstances, where development is not needed to render the eligibility determination, the EC shall indicate in the acknowledgement letter that the eligibility determination shall be mailed or otherwise transmitted in writing to the beneficiary within 60 calendar days of receipt of the request for review (see proposed 42 CFR 405.932(d)).

2. If the beneficiary’s initial request includes all information (including relevant information, medical records, or other documentation related to the hospital and SNF services) to render the eligibility determination, the EC shall indicate in the acknowledgement letter that the eligibility determination shall be mailed or otherwise transmitted in writing to the beneficiary within 60 calendar days of receipt of the request for review (see proposed 42 CFR 405.932(d)).

3. If the beneficiary’s initial request is valid but does not include all information or medical records or other documentation related to the hospital and SNF services to determine eligibility, the EC shall notify the beneficiary (or their representative) in the acknowledgement letter that the EC shall work with the MAC via MAS action, on the beneficiary’s behalf, to obtain the necessary information from the hospital and SNF (as applicable) to support the eligibility determination. (See, Task 5.) The acknowledgement letter shall also clarify that there will be an extension to the timeframe by which the decision will be completed by the EC. Additional details regarding what feedback to provide in the acknowledgement letter in these scenarios shall be developed in collaboration between the EC and CMS upon contract modification. (see proposed 42 CFR 405.932(c)).

a. If the EC misroutes an eligibility case to an incorrect MAC- either through error, multistate Provider not being within a certain MAC jurisdiction, or other scenario; the EC shall 1) close the case in MAS with a Decision value of “MAC Misroute”, 2) create a new case in MAS with a new appeal number, and 3) issue a Misroute Notification letter to the beneficiary informing them of their new patient status appeal number (template notice to be developed by CMS with collaboration from the EC). TheCOR and MAS System maintainer will provide additional guidance on these scenarios and related actions that may need to be taken.

Task 5: Review Valid Requests to Determine if the Request is Filed by (or on behalf of) an Eligible Party Under the Retrospective Review Process Once the EC has received a valid request (i.e., per Task 4, one that is timely and includes the minimum required elements for a request), it shall determine whether the request is eligible for an appeal under this new appeal process (i.e., is filed by, or on behalf of, an eligible party and meets all conditions required in the regulation). The EC shall review all documentation submitted with the request to determine the following:

1. Was the beneficiary formally admitted as a hospital inpatient on or after January 1, 2009?

2. While in the hospital, was the beneficiary reclassified by the hospital from an inpatient to an outpatient receiving observation services? There must have been a valid order for observation services and those services must have been furnished after the hospital reclassified the beneficiary as an outpatient.

3. Did the beneficiary receive an initial determination (as defined in 42 CFR 405.920) or Medicare Outpatient Observation Notice (MOON), applicable on or after the March 8, 2017, (the implementation date of the MOON requirements), indicating that the services furnished were not covered under Medicare Part A?

4. Was the beneficiary either (a) not enrolled in Medicare Part B coverage at the time of the hospitalization; or (b) stayed at the hospital for three or more consecutive days but was designated as inpatient for fewer than three days, unless more than 30 days has passed after the hospital stay without the beneficiary’s having been admitted to a skilled nursing facility?

5. Did the beneficiary previously file an appeal for the hospital or SNF services and receive a final decision before September 4, 2011? If so, then the beneficiary is not eligible for an appeal under the new process.

If the there is adequate information provided with the appeal request to verify that #1-4 are answered in the affirmative, and the response to #5 is no, then the request is eligible for an appeal. However, if the request does not include enough information (or documentation) for the EC to determine if the beneficiary has satisfied the eligibility requirements, the EC shall work with the Part A MACs to obtain additional information, if warranted to render the decision (see earlier examples where development may not be needed to determine if the beneficiary is or is not eligible). Such information may include claim information for claims submitted to the MAC and medical records and other documentation from the hospital and SNF that furnished services to the beneficiary.

Note: We anticipate in most cases, the beneficiary will not have all required information available to submit with their appeal request, and thus, medical records/documentation must be requested from the providers. Medical records will assist the EC in determining whether the beneficiary meets some of the eligibility requirements, including that observation services were furnished after the change in patient status from inpatient to outpatient. In addition, for administrative efficiency, the medical record requests made by the MAC on behalf of the EC (as described, below) shall be used to begin assembling a case file to support any future appeal adjudications regarding whether the Part A coverage requirements have been met for the hospital and SNF services.

If the EC cannot definitively verify eligibility based on the information provided in the appeal request, the EC shall:

• Enter as much information as available, based on the request received, on the Claim Research Form in MAS (to be developed by CMS in collaboration with the EC and the MAS System Maintainer prior to the operational date) and transmit to the MAC that processed the related hospital claim (or has since assumed responsibilities for claims processed in that respective Part A MAC jurisdiction) for further research of Medicare Part A and Part B claims data and to request records from the hospital and SNF. This form will include information regarding hospital and, as applicable, SNF services provided in the appeal request and will be transmitted to the Part A MAC via MAS or other secure mechanism, as determined in coordination with CMS and the MAC. At a minimum, the form shall request the MAC research the claims data and provide the following information so that the EC may determine:

• The hospital name (confirming information provided in the request).

• The dates of service for the hospital stay (confirming information provided in the request), and whether the beneficiary’s hospital stay was 3 or more consecutive days, with fewer than 3 days as an inpatient.

• Whether there was an initial determination for the outpatient hospital claim and the date of the initial determination.

• Whether there is a Condition Code 44 on the outpatient claim to indicate reclassification from inpatient to outpatient.

• Whether there are observation services billed on the outpatient claim.

• Whether the beneficiary was enrolled in Medicare Part B at the time of hospitalization.

• If a claim was submitted for SNF services (and the request contains the appropriate attestation), the name of the SNF and the dates of service for SNF services provided to the beneficiary. Note: to be eligible for this appeal process, the SNF services must have been received within 30 calendar days of discharge from the hospital.

• Whether an appeal was previously filed for the hospital and/or SNF claim and whether there was a final decision issued on or after September 4, 2011. Note: further research may be required, with the assistance of CMS, to determine when a final decision was rendered for any appeals filed.

The MAC shall complete its review of the claims data, populate the Claims Research Form with the available information, and securely send the form to the EC (via upload into MAS or other secure process as determined by the CMS, the EC, and MAC) within 21 calendar days of receipt of the form from the

EC.

Upon receipt of the Claims Research Form, the EC shall review the information provided by the MAC and beneficiary (or their representative) and determine whether the beneficiary is not eligible for an appeal or whether additional documentation (i.e., medical records from the hospital and, as applicable, the SNF) is needed to render the eligibility determination.

Note: If the MAC response to the Claims Research Form indicates that it is unable to identify the hospital outpatient claim and, as applicable, any claim for SNF services following the hospital stay, the EC shall contact the beneficiary (or their representative) in writing to request additional information or clarification regarding the previously identified hospital stay and, as applicable, SNF stay (e.g., provider name, dates of service, etc.). The EC shall afford the beneficiary (or their representative) 14 calendar days from receipt of the request for information to respond. The date of receipt of the request for information letter is presumed to be five (5) calendar days from the date of the letter unless there is evidence to the contrary.

• If the EC receives written clarification from the beneficiary (or their representative), then the EC provides this information to the MAC for further research by uploading the revised Claims Research Form with the corrected information within two (2) business days of receipt from the beneficiary (or their representative) so that the MAC can resume research of the claims data.

• The Part A MAC will have 21 calendar days to research the claims data with the new information provided by the beneficiary (or their representative), update the Claims Research Form, and send the form back to the EC for determination as to whether medical or other documentation should be requested from the hospital or SNF.

• Upon receipt of the revised Claims Research Form, the EC shall review the completed/updated information provided by the MAC and beneficiary and determine whether the beneficiary is eligible for an appeal or whether additional documentation (i.e., medical records from the hospital and, as applicable, the SNF) is needed to render the eligibility determination.

If upon review of the completed Claims Research Form, the EC needs additional documentation from the hospital and SNF to make an eligibility determination, the EC shall securely notify the MAC (via MAS or other secure process as determined by the CMS, the EC, and MAC), that records must be requested to render the eligibility determination. The Part A MAC shall issue the request for additional documentation request (ADR) letters (for medical documentation or other missing information) to the hospital and the SNF within seven (7) calendar days of receipt of notification from the EC. The Part A MAC shall allow providers up to 120 calendar days to respond with the requested medical or other documentation and shall carbon copy the beneficiaries on the ADR letters issued to both the hospital and SNF. Upon issuance of the ADR letters, the Part A MAC shall promptly upload the completed Eligibility Research Form and ADR letters into the MAS.

MAC Actions After Issuance of ADR Letters to Hospital and SNF:

Hospital and SNF Respond to Documentation Request: Within seven (7) calendar days of receipt of documentation from the hospital and, if applicable, the SNF, the Part A MAC shall securely upload the related documentation into MAS and notify the EC that the documentation has been received and is ready for the EC’s review.

No Response or Partial Response to Initial Documentation Request: The MAC shall notify the EC, via MAS or as otherwise directed by CMS, if either the hospital or SNF, or both failed to respond to the documentation request by the 121st calendar day after the MAC issued the request for documentation. If the MAC notifies the EC that neither the hospital nor SNF or only one entity provided the requested information, the EC shall proceed with the determination using any documentation received, as applicable, and notify the beneficiary (or their representative) in writing (see Task 6) regarding the outcome.

Task 6: Provide Written Notice Regarding the Outcome of the Eligibility Determination In accordance with proposed 42 CFR 405.932(d)(1)(ii), the EC shall review the information submitted with the appeal request and any additional information it obtains to determine if the beneficiary is an eligible party and that the services previously furnished are eligible for an appeal under proposed 42 CFR

405.931. The EC shall mail or otherwise transmit its determination via a written notice to the eligible party (or the party’s representative) within 60 calendar days of receipt of the appeal request unless subject to an extension as provided in the regulation.

As noted above, the adjudication deadline for issuing an eligibility decision is extended if the EC requests additional information from the beneficiary (or their representative) to determine if an appeal is valid or good cause is established for an untimely appeal. The 60-calendar day timeframe for the EC to issue notice of its determination is paused (tolled) for the time period between the request for information from the beneficiary (or their representative) and/or from the MAC with regards to the validation of the claims research form until receipt of the requested information from the beneficiary or MAC. Similarly, if the MAC requests records from the hospital and/or SNF on behalf of the EC that are missing and are needed to determine a beneficiary’s eligibility for an appeal, then the 60-calendar day timeframe for the EC to issue notice of its determination is paused (tolled) for the time period between the request for the records and receipt of the records (or in the case of non-receipt of records, the applicable time allowed for submission of the records). The EC’s completion timeframe shall resume on the date the MAC uploads the records received from the hospital and SNF into the MAS and routes the case back to the EC. If no records are received (or only records from either the hospital or the SNF), the EC’s completion timeframe shall resume on the calendar day following the day the records were due (i.e., the 121st calendar day). Additional details will be provided by CMS upon contract award/modification related to this process.

EC Actions When the MAC does not Receive a Response to Record Requests, or the Organization is Closed/No Longer in Business:

After notification from the MAC regarding a lack of response to the documentation requests, or a closure in the related hospital or SNF organization with no ability to obtain the related documentation (i.e., no transfer of provider files to a new entity about closure), the EC shall proceed with completing the eligibility determination based on the available information in the case file.

Acceptance of Appeal Request:

Following a determination that the beneficiary is an eligible party, the EC shall issue a notice of acceptance to the beneficiary (or their representative) explaining that the appeal has been accepted for processing and will be referred to the processing contractor (i.e., the MAC) for adjudication. The notice shall inform the beneficiary (or their representative) that no additional action is needed and that the appeal will automatically be routed to the MAC for processing of the level 1 appeal by the EC. The notice shall be written in a manner to be understood by the eligible party (or their representative). CMS will work collaboratively with the EC to develop a template for acceptance decisions.

Denial of Appeal Request:

As applicable, for an appeal that is not valid, is untimely (absent good cause), did not satisfy the requirements for an eligible party, or the services previously furnished are not otherwise eligible for an appeal, the EC shall issue a denial notice to the individual who filed the appeal request (or their representative). The notice shall explain that the request is not eligible for an appeal, and the reason(s) for the denial of the request, and the process for requesting a review of the eligibility determination. The notice shall be written in a manner to be understood by the beneficiary (or their representative). CMS will work collaboratively with the EC to develop template(s) for denial notices.

Request for Review of a Denial:

Under 42 CFR 405.932(e), CMS establishes the guidelines for requests for review of a denial of an appeal request. The EC shall follow the requirements in the regulation for handling and processing requests for review of such denials.

Requests for review of a denial by the EC must be received by the EC no later than 60 calendar days from the date the beneficiary (or their representative) receives the denial notice from the EC (note: the date of receipt of the denial notice is presumed to be 5 days after the date of the denial notice unless there is evidence to the contrary that the denial notice was not received by the beneficiary (or their representative) within the presumed 5 calendar days following the date of the notice (see proposed 42 CFR 409.931(f)). A request for review of a denial notice must be accepted after the 60-calendar day deadline if good cause is established in accordance with the provisions in 42 CFR 405.942(b)(2) and (3).

The EC shall ensure the review of a denial notice is conducted by an individual not involved with the initial denial determination.

Outcomes of Request for Review (Affirm, Reverse, or Dismiss):

A decision affirming or reversing the initial denial of the request for an appeal, or a dismissal of the request for review, shall be issued in accordance with the regulation within 60 calendar days of the date of the receipt of the request for review.

• If the EC reverses the initial denial of the request for appeal, the EC shall close the request in the

MAS in accordance with the timeframes noted in Task 8 to expeditiously forward the approved request for appeal to the processing contractor. (see proposed 42 CFR 405.932(e)(7)).

• If the EC affirms the initial denial of the request for appeal, the denial is binding and not subject to further review (see proposed 42 CFR 405.932(e)(8)).

• If the beneficiary (or their representative) submits a request for review of a prior denial due to untimely filing, the EC shall consider all evidence submitted and either reverse the prior denial if good cause is established for the untimely filing or deny the request for review if good cause is not established. The denial is binding and not subject to further review (see proposed 42 CFR 405.932(e)(7) – (8)). If the EC reverses the prior denial due to untimely filing, it shall notify the beneficiary and indicate that the EC will now take action to review the patient status appeal request.

The EC shall create a new appeal in MAS, for this action, and shall have 60 calendar days to issue the determination (unless subject to the applicable tolling etc. occurs consistent with the claims research and documentation request process as described in this appendix).

• If the beneficiary (or their representative) submits a request for review of a prior denial due to an invalid request, the EC shall consider all evidence submitted and either reverse the prior denial if the missing information(s) has now been provided or affirm the prior denial. The denial is binding and not subject to further review (see proposed 42 CFR 405.932(e)(7) – (8)). If the EC reverses the prior denial because the issue has been cured and the patient status request is now valid, it shall notify the beneficiary and indicate that the EC will now take action to review the patient status appeal request.

The EC shall create a new appeal in MAS, for this action, and shall have 60 calendar days to issue the determination (unless subject to the applicable tolling etc. occurs consistent with the claims research and documentation request process as described in this appendix).

Untimely Requests for Review:

• If the EC receives a request for review of a prior denial and the request is not filed timely, the contractor shall review the request and all documentation received to determine if good cause has been established for untimely filing. In determining whether good cause for untimely filing exists, the EC applies the provisions in 42 CFR 405.942(b)(2) and (3). If good cause is established, the EC shall process the request for review and either affirm or reverse the prior denial. The decision to affirm or reverse the prior denial, as applicable, is binding and not subject to further review. If good cause for untimely filing is not established, the EC shall dismiss the request for review. The dismissal is binding and not subject to further review (see proposed 42 CFR 405.932(e)(2) and 405.932(e)(9)).

CMS will work collaboratively with the EC to develop a template for the dismissal notice.

Task 6a: EC Actions When Untimely Documentation is Received In the rare instance a hospital or SNF provides the MAC with the previously requested documentation after the 120th calendar day from the MAC’s request, the EC shall:

Consider the documentation prior to issuance of the eligibility determination, as applicable. Alert the COR if this impacts the ECs ability to timely issue the eligibility determination.

If the EC has already issued an eligibility determination, the EC will contact the COR for guidance.

Task 7: Notify…