MLN Matters Number: MM5836
Related Change Request (CR) #: 5836
Related CR Release Date: January 11, 2008
Effective Date: January 1, 2008
Related CR Transmittal #: R1408CP
Implementation Date: February 11, 2008
Provider Types Affected: All physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), regional home health intermediaries (RHHI), Medicare Administrative Contractors (A/B MAC), or Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for services provided or supplied to Medicare beneficiaries.
What You Need to Know: CR 5836, from which this article is taken, modifies the Reconsideration Request Form that is included with the model Medicare Redetermination Notice (for partly or fully unfavorable redeterminations), to clarify the minimum set of elements on the form that you must complete in order for the request to be considered valid for reconsideration.
You should make sure that your billing staffs are aware that they must complete items 1, 2a, 6, 7, 11 & 12 on this Reconsideration Request Form.
Background: The Reconsideration Request Form modification that CR 5836 requires is necessary because the current Medicare manual instructions do not clearly identify all of the elements required for a reconsideration request to be considered valid in accordance with Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) Section 405.964(b).
The modification to the form is as follows:
'Directions: If you wish to appeal this decision, please fill out the required information below and mail this form to the address shown below. At a minimum, you must complete/include information for items 1, 2a, 6, 7, 11 & 12 but to help us serve you better, please include a copy of the redetermination notice with your request.'
Those elements that, as a minimum, you must complete in the form are:
1. Name of Beneficiary
2a. Medicare Number
6. Item or service you wish to appeal
7. Date of the service (From and To dates)
11. Name of Person Appealing
12. Signature of Person Appealing/Date
Additional Information: You can find more information about the modification to the model Medicare Redetermination Notice (for partly or fully unfavorable redeterminations) by going to CR 5836, located at http://www.cms.hhs.gov/Transmittals/downloads/R1408CP.pdf on the CMS website. The updated Medicare Claims Processing Manual, Chapter 29, Section 320.7 (Medicare Redetermination Notice (for partly or fully unfavorable redeterminations)) is an attachment to that CR. The Reconsideration Request Form is also attached to CR5836.
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Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.