In the Know

CMS Releases MLN Matters Related to Appeals of Claims Decisions
May 1, 2019
Alerts
Arnall Golden Gregory LLP

On April 12, 2019, CMS released a Medicare Learning Network Matters article (MLN) in connection with Change Request (CR) 11042, which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 – Appeals of Claims Decisions). The MLN is for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospices (HH&H) MACs for services provided to Medicare beneficiaries. The revisions become effective June 13, 2019.

More specifically, CR 11042 incorporates the following updates to the Medicare Claims Processing Manual:

  • The policy on use of electronic signatures;
  • Timing of signatures on transfer of appeal rights and the appointment of representative forms;
  • Tolling on adjudication timeframe when trying to cure a defective appointment form;
  • Limiting scope of redetermination review in certain instances;
  • Application of good cause for late filing involving beneficiary accessibility; and
  • Application of good cause where there is a declared disaster.

See CMS, MLN Matters Number MM11042, Pub. 100-04, Chapter 29 – Appeals of Claims Decisions Revisions at 1 (Apr. 12, 2019).

CR 11042 revises the Medicare Claims Processing Manual to add policy clarifications regarding appeals of claims decisions. Those revisions include:

  • MACs must document when they find “good cause for late filing on the appeal decision letter or the appeal case file”;
  • MACs will observe additional procedures for appeals when a natural or man-made disaster occurs;
  • “MACs will observe the amendments to accepted forms of signatures, which state that all signatures may be handwritten or electronic, digital, and/or digitized. Electronic, digital, and/or digitized signatures are acceptable for appointment of representative instruments providers submit via mail, facsimile, or a CMS-approved secure Internet portal/application”;
  • “MACs will observe tolling of timeframe when attempting to cure a defective appointment instrument. Where an adjudication time frame applies, the time from the later of the date that a defective appointment of representative was filed or the current appeal request was filed by the prospective appointed representative, to the date when the defect was cured, the party notifies the adjudicator that he or she will proceed with the appeal without a representative, or the 30-day deadline for curing the defect has elapsed with no response, does not count towards the adjudication time frame”; and
  • “Where an adjudication time frame applies, the time from the later of the date that a defective appointment of representative was filed or the current appeal request was filed by the prospective appointed representative, to the date when the defect was cured, the party notifies the adjudicator that he or she will proceed with the appeal without a representative, or the 30-day deadline for curing the defect has elapsed with no response, does not count towards the adjudication time frame.”

Id. at 1–2.

For the MLN Matters article, please click here.

For the official instruction, CR 11042, please click here.

For more information regarding the above information, please contact Brittany Strandell.