Reconsideration By Qualified Independent Contractor

A party to a redetermination (level-one appeal) may request a reconsideration if dissatisfied with the redetermination.

• Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provisions aimed at improving the Medicare fee-for-service appeals process. Part of these provisions mandate that all second-level appeals for both Part A and Part B (also known as reconsiderations) be conducted by Qualified Independent Contractors (QICs).
• Reconsiderations now conducted by QICs replace the Hearing Officer Hearing process for Medicare Part B claims and established a new second-level of appeal for Medicare Part A claims.
• The introduction of QICs allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals.
• No minimum monetary threshold is required to request a reconsideration.

Requesting a Reconsideration

A written reconsideration request must be filed within 180 days of receipt of the redetermination. Notice of initial determination is presumed to be received 5 days from the date of the notice unless evidence to the contrary

To request a reconsideration, follow the instructions on the Medicare Redetermination Notice (MRN).

• A request for a reconsideration may be made on Form CMS-20033 or
• If the form is not used, the written request must contain all of the following information:
  • Medicare Health Insurance Claim (HIC) number
  • Specific service(s) and/or item(s) for which the reconsideration is requested
  • Specific date(s) of service
  • Name and signature of the party or the authorized or appointed representative of the party
  • Name of the contractor that made the redetermination

Supporting Documentation

• All evidence for the appeal must be submitted at this level unless good cause shown
• The request should clearly explain the disagreement with the redetermination.
• A copy of the MRN and any other useful documentation should be sent with the reconsideration request to the QIC identified in the MRN.
  • Documentation that is submitted after the reconsideration request has been filed may result in an extension of the timeframe a QIC has to complete its decision.
  • Any evidence noted in the redetermination as missing and any other evidence relevant to the appeal must be submitted prior to the issuance of the reconsideration decision.
  • Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless good cause is shown for submitting the evidence late.

Decision Notification

• QIC is NOT bound by Local Coverage Determinations (LDCs)
• Reconsiderations are conducted on-the-record and, in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration.
• The decision will contain detailed information on further appeals rights if the decision is not fully favorable - including details regarding the procedures for requesting an Administrative Law Judge hearing (level-three appeal).
• If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to the next level of appeal.

Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) enacted numerous contracting reforms that can impact the claims audit and appeals processes. Check often for new developments: Medicare Contracting Reform Updates