Upcoming Webinars

  • No upcoming events

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Menu
Log in

Level 2: Reconsideration 

Medicare Reconsideration Request Form CMS-20033

Filing a Request for a Reconsideration

The request for a reconsideration made by a beneficiary, provider, supplier, or State must be filed with the QIC specified in the redetermination notice. A request from a provider, supplier, or State must be made in writing either on the Form CMS-20033 (the reconsideration request form included with the redetermination), or must contain the following items:

    • The beneficiary’s name;
    • Medicare health insurance claim number;
    • The specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service;
    • The name and signature of the party or representative of the party filing the request; and
    • The name of the contractor that made the redetermination.

Time Limit for Filing a Request for a Reconsideration

A party must file a request for reconsideration within 180 days of the date of receipt of the notice of the redetermination. The date of filing for requests filed in writing is defined as the date received by the QIC in their corporate mailroom. If the party has filed the request in person with the QIC, the filing date is the date of filing at such office, as evidenced by the receiving office’s date stamp on the request. If the party has mailed the request for reconsideration to a CMS, SSA, RRB office, or another government agency in good faith within the time limit, and the request did not reach the appropriate QIC until after the time period to file a request expired, the QIC considers the request as timely filed. Likewise, if the request is filed with CMS, SSA, RRB, or another government agency in person, the QIC considers the request as timely filed.

QIC Review of a Dismissal of a Redetermination Request

If a MAC has dismissed a redetermination request, any party to the redetermination has the right to appeal a dismissal of a redetermination request to a QIC if they believe the dismissal is incorrect. The request for review must be filed with the QIC within 60 days after the date of receipt of the dismissal. When the QIC performs its review of the dismissal, it will only decide on whether or not the dismissal was correct. If it determines that the MAC incorrectly dismissed the redetermination, it will vacate the dismissal and remand the case to the MAC for a redetermination. See “First Level of Appeal” webpage (left navigation bar) for more information on MAC dismissals.

Dismissal of a Reconsideration Request

A QIC may dismiss a reconsideration request in the following instances:

         If the party (or appointed representative) requests to withdraw the appeal; or

         If there are certain defects, such as

o   The party fails to file the request within the appropriate timeframe and did not show (or the QIC did not accept) good cause for late filing

o   The representative is not appointed properly

o   The requestor is not a proper party

Parties to a QIC's dismissal of a request for reconsideration have 2 options if they disagree with the dismissal:

         Request review of the dismissal by an Administrative Law Judge (ALJ,) or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA)

         Request that the QIC vacate the dismissal

Reconsideration Decision Notification

The reconsideration decision will contain detailed information on further appeals rights, where applicable. Generally, the QIC will send this decision to all parties within 60 days of receipt of the request for reconsideration. If the QIC is unable to complete its reconsideration within this timeframe (with exceptions for extensions for additional evidence submissions and late filing), the QIC must send a notice to the parties and advise the appellant of the right to escalate the appeal to OMHA. If the party chooses to escalate the appeal to OMHA, a written request must be filed with the QIC in accordance with instructions on the escalation notice.



Copyright Med Comply LLC 2020

Med Comply does not claim copyright over US Federal and State materials

CPT codes are copyright 1995-2020 American Medical Association. All rights reserved.


Powered by Wild Apricot Membership Software