Wednesday, April 17, 2019

CMS Issues Significant Revisions to Appeals of Claims Decisions Chapter 29 of the Medicare Claims Processing Manual

Dan Ciolek

On April 12, the Centers for Medicare and Medicaid Services (CMS) MLN Matters Article MM11042 announced the publication of Change Request CR 11042, Transmittal R4278CP, which includes significant updates to Chapter 29 of the Medicare Claims Processing Manual associated with the process of appealing claims decisions.  The effective and implementation dates for these changes is June 13, 2019.  Provider billers and audit/compliance staff are encouraged to review these changes.

SUMMARY OF CHANGES: 
This Change Request (CR) updates Pub. 100-04, Chapter 29 with several policy updates, including electronic signatures, limiting scope of redetermination review in certain instances, application of good cause for late filing involving beneficiary accessibility, as well as application of good cause where there is a declared disaster.  As more Medicare Administrative Contractors (MACs) are brought on board to the Medicare Appeals System (MAS), instruction is being added related to MAS processing functions.  In addition, the requirement for both signatures on an appointment of representative instrument and the Assignment of Appeal Rights form to be made within 30 days of each other is being removed.  There are also minor grammar or formatting corrections made throughout the chapter.  Changes in the appeals regulations at 405 subpart I are incorporated, which include tolling an adjudication timeframe when trying to cure a defective appointment form, as well as changes relative to the third level of appeals handled by the Office of Medicare Hearings and Appeals (OMHA).

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