Medicare Revises Their Appeals Process

April 29th, 2019 - Wyn Staheli, Director of Research
Categories:   Medicare   Billing  
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On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place:

  • The policy on use of electronic signatures
  • Timing of signatures on transfer of appeal rights and the appointment of representative forms
  • Tolling an 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
  • Application of good cause where there is a declared disaster: There are new instructions about what constitutes a disaster and what is allowed

— MLN Matters #MM11042

Of all these revisions, unless you are in a disaster area, the ones that will primarily affect most appeals are:

  • Electronic signatures are acceptable for submitting the appointment of a representative, as long as you use a CMS-approved secure Internet portal/application.
  • If there is a problem with the appeal request or a transfer of appeal rights, the MAC can notify the provider and/or beneficiary using mail, fax, or a secure internet portal/application.
  • Appeals need to include both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI). There will likely be a new form that you will need to be using to ensure that you have both these required items.
  • Extra time is allowed if the beneficiary asks for documents to be converted into an accessible format  (e.g., large print, Braille) or if they are getting help, due to a disability, from someone else (e.g., senior center) to file the appeal for them.
  • Amount in controversy changes — be sure to review all the red in section 250.2 of the MCPM (see References below).

The ongoing problem of the backlog of appeals necessitated some of the changes to MCPM. Throughout Chapter 29, there are numerous references to the Attorney Adjudicator Review at the Office of Medicare Hearings and Appeals (OMHA) as well as the Administrative Law Judge (ALJ).

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