[Federal Register Volume 60, Number 131 (Monday, July 10, 1995)]
[Proposed Rules]
[Pages 35544-35548]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-16807]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Part 405
[BPO-121-P]
RIN 0938-AG48
Medicare Program; Telephone and Electronic Requests for Review of
Part B Initial Claim Determinations
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would allow beneficiaries, providers, and
physicians (and other suppliers), who are entitled to appeal Medicare
Part B initial claim determinations, to request a review of the
carrier's initial determination by telephone or electronic
transmission. (Currently, a request for review may be made only in
writing.) Allowing the use of telephone and electronic requests would
expedite the review process by supplementing, not replacing, the
current review procedures. It would also improve carrier relationships
with the provider and beneficiary communities by providing quick and
easy access to the appeals process. (This rule would not provide for
telephone or electronic requests for review of Part B initial
determinations made by Peer Review Organizations and Health Maintenance
Organizations.)
DATES: Comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on
September 8, 1995.
ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPO-121-P, P.O. Box 26688,
Baltimore, MD 21207.
If you prefer, you may deliver your written comments (1 original
and 3 copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPO-121-P. Comments received timely will be available for
public inspection as they are received, generally beginning
[[Page 35545]]
approximately 3 weeks after publication of a document, in Room 309-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7890).
For comments that relate to information collection requirements,
mail a copy of comments to: Allison Herron Eydt, HCFA Desk Officer,
Office of Information and Regulatory Affairs, Room 10235, New Executive
Office Building, Washington, DC 20503.
FOR FURTHER INFORMATION CONTACT: Rosalind Little, (410) 966-6972.
SUPPLEMENTARY INFORMATION:
I. Background
Under current Medicare regulations, if a party indicates
dissatisfaction with a Part B initial determination on a claim, either
a review is made in accordance with regulations set forth in 42 CFR
405.807 (Review of initial determination) and section 12010 of the
Medicare Carriers Manual (effective October 1990) or the request is
dismissed if the appellant is not a proper party. (``Party'' is defined
at Sec. 405.802 as a person enrolled under Part B of title XVIII, his/
her assignee, or other entity having standing in the initial or
appellate proceedings.)
Section 405.807 sets forth the review process to be followed by a
party who is dissatisfied with an initial determination by a carrier. A
party is currently required to file a written request for review of the
initial determination with the carrier, the Social Security
Administration, or HCFA within 6 months after the date of the notice of
the initial determination. The carrier may, upon request by the party,
extend the time period to file a request for review if it finds the
party had good cause for failing to request a timely review. The
review, an independent reexamination of the entire claim, is performed
by carrier staff who played no part in making the initial
determination.
``Supplier'' is defined at Sec. 400.202 as a physician or other
practitioner, or an entity other than a ``provider,'' that furnishes
health care services under Medicare. Although ``supplier'' encompasses
physicians, for clarity in this document, we refer to both
``physicians'' and ``suppliers''.
``Provider'' is defined at Sec. 400.202 as a hospital, a skilled
nursing facility, a comprehensive outpatient rehabilitation facility, a
home health agency, or a hospice, that has in effect an agreement to
participate in Medicare, or a clinic, a rehabilitation agency, or a
public health agency that has a similar agreement but only to furnish
outpatient physical therapy or speech pathology services.
Under section 1879(d) of the Social Security Act (the Act), a
provider, or a physician or other supplier that accepts assignment to
furnish services to Medicare beneficiaries has the same appeal rights
as an individual beneficiary under certain limited circumstances if the
issue in dispute involves medical necessity or custodial care or home
health denials involving the failure to meet homebound or intermittent
skilled nursing care requirements. Additionally, regulations at 42 CFR
part 405, subpart H (Appeals Under the Medicare Part B Program) provide
that a supplier or physician that has taken assignment of a Part B
Medicare claim has the same appeal rights as the beneficiary.
II. Proposed Changes to the Procedures for Requesting a Review
We propose to change the Medicare regulations at Sec. 405.807 to
allow a party to request a review of a Part B initial claim
determination by telephone or by electronic transmission, in addition
to the current provisions for a written request. The term ``electronic
transmission'' would refer to tape-to-tape, disk-to-disk, or any other
HCFA-approved electronic media form for electronic transmission. Fax
machine transmissions would not be considered ``electronic
transmissions.'' We have included in this section proposed methods for
allowing parties to request a review by telephone or electronic
transmission.
A. Telephone Requests for Review
The notice accompanying the carrier's initial determination, which
explains how to initiate a request for review, would include the
telephone number designated by the carrier for making review requests.
If an appellant initiates a request for review by telephone, the
carrier would assign the request a confirmation number. During the
telephone discussion, the appellant would be given the confirmation
number and the name of the person who received his or her telephone
request. It is important that the confirmation number be kept by the
party requesting a review. If it is unclear to the carrier that a
request was filed or filed timely, the confirmation number would assist
the carrier in locating its records of the telephone request. While
providing a confirmation number serves as additional protection for the
appellant, loss of the number would not affect access to the appeal
process and or appeal records.
We believe that allowing appellants to initiate a request for
review by telephone would facilitate easier access to the appeals
process. We recognize, however, that there may be instances in which
the appellants may have difficulty in reaching a carrier by telephone.
In order to ensure that appellants who encounter difficulties have
sufficient time to file a written request for review by the 180-day
deadline, we would limit the period to request a review by telephone to
a period of 150 days after the date of the notice of the initial
determination. This shorter period for initiating a review by telephone
would afford an appellant who may be unsuccessful in reaching a carrier
by telephone an additional ``window of opportunity'' to make a written
request for review before the time to appeal expires.
We believe that providing this window would establish a safeguard
for appellants who were unable to reach the carrier by telephone. This
safeguard is necessary because of difficulty verifying that the
appellant could not reach the carrier by telephone. Therefore, if the
appellant telephoned the carrier on the 150th day and could not get
through, he or she would still have an additional 30 days to submit a
written request for review.
We intend to establish instructions for carriers that would ensure
that the right to a review is not compromised. These instructions would
include, but may not be limited to, the following:
B. Requests for Review
The carrier's initial claim notice must specify the
telephone number that a party dissatisfied with the initial
determination can call to request a review. The initial claim notice
must also specify the timeframe for requesting review by telephone
(that is, 150 days), as well as the timeframe for filing a written
request for review (that is, 180 days).
The carrier must inform and educate the beneficiaries
about its telephone review process through any one of the following:
--Bulletins/newsletters.
--Newspaper articles.
--Senior citizen groups.
--Beneficiary outreach workshops.
--Carrier's customer service/inquiry department.
--Provider relations department.
The carrier must document all telephone calls at the time
a call is received. The carrier must record the date the appellant
called and the confirmation number assigned to assure timely filing.
[[Page 35546]]
The carrier must attempt to resolve as many issues as
possible during the telephone conversation. Some telephone reviews may
not be processed or completed because of the complexity of issues, need
for additional documentation, or other factors. At the end of each
telephone review, the carrier must advise the appellant of further
appeal rights.
The carrier must give the appellant a written
determination advising him or her of the results of the review,
regardless of whether a review is requested by telephone, in writing,
or via electronic transmission.
C. Electronic Requests for Review
Filing review requests electronically would be easier and faster
for parties than submitting a letter or the HCFA-1964 form (Request for
Review of Part B Medicare Claim). Electronic requests would shorten the
mailing time for submitting review requests and eliminate the paper
hassle of hardcopy requests. Currently, not all of the carriers have
the capacity to receive electronic requests for review. However, in the
future all carriers will have the capability to accept electronic
requests for review from entities that submit their claims
electronically. We propose to provide for electronic requests for
review but to limit this process to those entities that electronically
bill their claims to a carrier system that has the capability to
receive electronic requests for review. We would instruct carriers to
inform their billers whenever they obtain this capability and inform
them how the process works.
The following steps show how the electronic process is expected to
work:
Once the biller electronically receives notification of
the initial claim determination from the carrier, he or she must enter
a ``specified code'' to indicate that the retransmission is a request
for review.
For each line of the claim being submitted for review, the
biller must indicate the reason for the review in the ``Notes'' field.
This request for review is transmitted to the carrier.
Any additional documentation the biller wants to submit
can be mailed, or with carrier agreement, faxed to the carrier.
An appellant would have a 180-day period to request a review of an
initial determination by electronic means, which is the same time
allowed to file a written request for review. The appellant submitting
an electronic request for review would receive an online
acknowledgement at the time of transmission. Therefore, the appellant
would have documentation that a request for review was filed and the
time of filing. Since the appellant who submitted an electronic request
would have more control over initiating the request for review than an
appellant who telephoned for a request, we are not limiting electronic
requests to 150 days.
The above explanation is being furnished simply to provide an idea
of the way the process should work. However, should this proposed rule
be finally implemented, the above process is not necessarily the exact
process that will be employed.
III. Reasons for the Revisions
Parties to a Part B determination, particularly physicians who take
assignment, often contact carriers by telephone to dispute a
determination that a service was not covered or to obtain information
about why they were paid less than they thought was reasonable.
Sometimes, physicians call because they believe the code assigned to
the service is incorrect, or they want to correct some other error they
believe the carrier made.
Many beneficiaries raise questions about initial determinations if
a denial or partial denial of a bill is involved. Beneficiaries often
want to know why charges were reduced, especially if they believe the
charges were reasonable.
As a result of these calls, carriers frequently make corrections by
telephone, calling the process a reopening, informal review, or other
name. This action requires administrative funds, even though the party
has not actually used the administrative review process. The carrier,
in effect, may do two reviews in place of one for each instance in
which the informal action does not satisfy the party.
A party that calls to inquire about the initial determination, we
believe, would be pleased to know he or she has the option of writing
or calling to request a review. Whenever possible, the carrier would
attempt to resolve issues during a call and provide a review
determination at the conclusion of the call. At the end of each
telephone review, the carrier would advise the party of further appeal
rights.
The current review process that requires a party to write to
request a review takes time and effort, especially for beneficiaries.
At times, the party requesting a review in writing may have to wait
approximately 45 days to receive a review determination. Our intention
in encouraging telephone requests for reviews is to foster quick
communication between the review staff and the parties. The proposed
additional means of requesting a review by telephone or electronic
transmission would improve customer service in the following ways:
Making access to the appeals process easier.
Saving time.
Providing a more prompt response.
Reducing paperwork. (Currently a party must write a letter
or complete HCFA Form 1964 (Request for Review) or submit a completed
EOMB to request a review.)
Ensuring prompt payments.
Improving our relationship with the beneficiary and
physician/supplier communities.
IV. Exclusions From Telephone and Electronic Reviews
We do not intend to provide for telephone requests for review on
Part B determinations made by Peer Review Organizations (PROs) because
of the types of issues PROs handle. The issues are usually medically
focused and highly technical. We also believe this process would not be
administratively efficient and reasonable, if, in most cases,
adjudication cannot occur at the time of the call. The process could
actually result in delays and/or duplication of effort. We believe the
issues and documentation needed to process PRO appeals are sufficiently
different from other Part B reviews and the telephone request process
would be cumbersome for these appeals.
Similarly, we do not intend to provide for telephone requests for
review on Part B initial determinations made by Health Maintenance
Organizations (HMOs). Requests for reconsideration of initial
determinations made by HMOs are governed exclusively by 42 CFR part
417, subpart Q. Unlike part 473, subpart B (PRO reconsiderations and
appeals process), there is no cross-reference to part 405, subpart H in
part 417, subpart Q.
Electronic requests for review would be available to those billers
that bill their claims to a carrier system that has the capability to
receive electronic requests for review. Although PROs may make the
review determination, it is the carrier or fiscal intermediary's
responsibility to process any adjustments to the claim, as a result of
the review determination. Since the PROs are not involved in the
billing process, the PROs would not need to have the capability to
receive claims and/or electronic requests for reviews.
V. Provisions of the Proposed Regulation
Under sections 205(a), 1102(a), 1871(a)(1) and 1872 of the Act, the
[[Page 35547]]
Secretary has the authority to prescribe regulations as may be
necessary to administer the Medicare program. It is under these
statutory authorities that we propose to change the Medicare
regulations to allow a party to request a review of a Part B initial
claim determination by telephone or by electronic transmission.
We propose to revise Sec. 405.807 (Review of Initial Determination)
as follows:
Redesignate existing paragraph (d) as new paragraph (b)
and remove the words ``in writing'' from newly redesignated paragraph
(b).
Redesignate existing paragraph (b) as paragraph (c) and
revise it to allow the additional methods of telephone and electronic
transmission for a party (other than a PRO) to request a review of an
initial determination by a carrier.
Redesignate existing paragraph (c) as paragraph (d) and
revise it to allow for a period of 150 days after the date of the
notice of the initial determination for a party to telephone the
carrier and request a review.
Add new paragraph (e) to clarify that a beneficiary,
provider, or attending practitioner who is dissatisfied with a PRO
initial determination may request a review of an initial determination
only in writing.
VI. Collection of Information Requirements
Section 405.807 of this document contains information collection
and recordkeeping requirements that are subject to review by the Office
of Management and Budget (OMB) under the Paperwork Reduction Act of
1980 (44 U.S.C. 3501 et seq.). These reporting and recordkeeping
requirements are not effective until a notice of OMB's approval is
published in the Federal Register. This proposed rule would impose
minimal recordkeeping requirements. We would require carriers to assign
a confirmation number to a party that initiates a request for review by
telephone. The party would be given the confirmation number by the
person who received his or her telephone request. We anticipate that
the confirmation number would be the same number the carrier uses as
its internal control number/documentation number (usually a 13-digit
number). If this can be done, there would not be any additional
recordkeeping on the carrier's part. The carrier is already assigning
this number and recording it.
The party who would be given the confirmation number would have to
record the number. This number would confirm that the party timely
filed a request should that become an issue later. The confirmation
number would assist the carrier in locating its record of the telephone
request. It would take less than one minute for the carrier to assign
and record the confirmation number and the same for the party to record
the confirmation number. While providing a confirmation number serves
as additional protection for the party, loss of the number would not
affect access to the appeal process and/or appeal records.
Organizations and individuals desiring to submit comments on the
information collection and recordkeeping requirements should direct
them to the OMB official whose name appears in the ADDRESSES section of
this preamble.
VII. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comments, we are
not able to acknowledge or respond to them individually. We will
consider all comments we receive by the date and time specified in the
``DATES'' section of this preamble, and, if we proceed with a
subsequent document, we will respond to the comments in the preamble to
that document.
VIII. Regulatory Impact Statement
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612), unless we certify that a rule would not have a
significant economic impact on a substantial number of small entities.
For purposes of the RFA, carriers and beneficiaries are not considered
to be small entities. We consider all providers, physicians, and other
suppliers to be small entities. Under this proposed rule,
beneficiaries, providers, and physicians and other suppliers may
request a review of an initial claim determination by telephone or
through electronic transmission. This review is the first level of
appeal for Part B claims and is performed by carrier staff who had no
part in making the initial determination. This review, without the
presence of oral testimony by the appellant party, is considered to be
less costly to all parties and is a more expeditious way of handling
complaints than a hearing.
Section 1102(b) of the Act requires us to prepare a regulatory
impact statement if a rule may have a significant impact on the
operations of a substantial number of small rural hospitals. Such an
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 50 beds.
We are not preparing a regulatory impact statement since we have
determined, and we certify, that this rule would not have a significant
economic impact on the operations of a substantial number of small
rural hospitals.
In accordance with the provisions of Executive Order 12866, this
proposed rule was not reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
42 CFR Part 405 would be amended as follows:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
1. The authority citation for part 405, subpart H is revised to
read as follows:
Authority: Secs. 205(a), 1102, 1842(b)(3)(C), 1869(b), and 1871,
and 1872 of the Social Security Act, as amended. (42 U.S.C. 405(a),
1302, 1395u(b)(3)(C), 1395ff(b), 1395hh and 1395ii.)
Subpart H--Appeals Under the Medicare Part B Program
2. Section 405.807 is revised to read as follows:
Sec. 405.807 Review of initial determination.
(a) General. A party to an initial determination by a carrier, who
is dissatisfied with the initial determination, may request that the
carrier review the determination. If a review is requested, the request
for review does not constitute a waiver of the right to a hearing
(under Sec. 405.815) subsequent to the review.
(b) Definition. Request for review is a clear expression by a party
to an initial determination that indicates he or she is dissatisfied
with the initial determination and wants to appeal the matter.
(c) Place and method of filing a request. Except for the limitation
on PRO requests set forth in paragraph (e) of this section, a request
by a party for a carrier to review the initial determination may be
made only in one of the following ways:
(1) In writing and filed at an office of the carrier or at an
office of SSA or HCFA.
(2) By telephone to the telephone number designated by the carrier
as the
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appropriate number for its receipt of requests for review.
(3) By electronic transmission to the carrier.
(d) Time of filing request. (1) For telephone requests, a party to
the initial determination may request a review of the initial
determination within 150 days after the date of the notice of the
initial determination.
(2) For requests made in writing or by electronic transmission, a
party to the initial determination may request a review of the
determination within 180 days after the date of the notice of the
initial determination.
(3) The carrier may, upon request by the party affected, extend the
period for requesting the review.
(4) For telephone requests, a party to the initial determination is
not precluded from later making a written or electronic request if
unable to contact the carrier within the 150 day timeframe. The party
has an additional 30 days to submit a written or electronic request for
review.
(e) Exception to telephone and electronic review requests. A party
that submits a request for review of a Medicare Part B initial
determination on a claim by a PRO must follow the submittal
requirements described in paragraph (c)(1) of this section.
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: June 28, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 95-16807 Filed 7-7-95; 8:45 am]
BILLING CODE 4120-01-P
