[Federal Register Volume 64, Number 189 (Thursday, September 30, 1999)]
[Rules and Regulations]
[Pages 52665-52670]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-25477]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Part 405
[HCFA-4121-FC]
RIN 0938-AG48
Medicare Program; Telephone Requests for Review of Part B Initial
Claim Determinations
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final rule with comment period.
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SUMMARY: Currently, our regulations allow beneficiaries, providers, and
suppliers (defined as physicians or other practitioners, or entities
other than a provider), who are entitled to appeal Medicare Part B
initial claim determinations, to request a review of the carrier's
initial determination in writing. This final rule allows those review
requests to be made by telephone and allows the carrier to conduct the
review by telephone, if possible. The use of telephone requests
supplements, and does not replace, the current written procedures for
initiating appeals. This telephone option also improves carrier
relationships with the beneficiary, provider, and supplier communities
by providing quick and easy access to the appeals process. Carriers
will make accommodations to enable a hearing impaired individual access
to the telephone review process.
EFFECTIVE DATE: These regulations are effective on February 1, 2000.
Comment date: Comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on
November 29, 1999.
ADDRESSES: Mail an original and 3 copies of written comments to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-4121-FC, P.O. Box 9013,
Baltimore, MD 21244-9013.
FOR FURTHER INFORMATION CONTACT:
Rosalind Little, (410) 786-6972.
SUPPLEMENTARY INFORMATION:
I. Background
Under current Medicare regulations at 42 CFR Part 405, Subpart H, a
party (a person enrolled under Part B of Medicare, his or her assignee,
or other entity having standing to appeal the determination in
question), that indicates dissatisfaction with a Part B initial claim
determination by a carrier, is entitled to have a carrier review
conducted in accordance with regulations set forth in Sec. 405.807
(Review of initial determination) and section 12010 of the Medicare
Carriers Manual (MCM). However, if the appellant is not a proper party
or the request for appeal review is not filed timely, the appellant's
request may be dismissed.
Currently, a request for the carrier review of an initial claim
determination is to be made in writing and filed with us, at an office
of the carrier, or at an office of the Social Security Administration
(SSA). The carrier must provide a period of 6 months after the date of
the notice of its initial determination within which a party may
request review. The carrier may, upon request by the party affected,
extend the period for requesting the review.
On July 10, 1995, we published a proposed rule in the Federal
Register (60 FR 35544) that would change the Medicare regulations to
allow a party to request the carrier review of its Part B initial claim
determination by telephone or by electronic transmission, in addition
to the current provisions for a written request.
II. Provisions of the Proposed Rulemaking
In the proposed rule, we stated that the reason for allowing
parties to request the review of a carrier's initial claim
determination by telephone or electronic transmission, in addition to
submitting written requests, was that we recognized that both
physicians and beneficiaries often call the carrier to dispute a
determination, to ask for clarification, or to protest a denial. We
also recognized that the current review process requiring a party to
submit a written request for a review can take considerable time and
effort. This is because at times it can be difficult to properly
explain a problem or ask a question in writing. In addition, a written
request provides no opportunity for the dialogue that allows parties to
discuss the issues and provide detailed explanations.
The proposed rule stated that telephone or electronic requests for
review of Health Maintenance Organizations (HMOs) and Peer Review
Organizations (PROs) Part B initial determinations must be made in
writing. This rule does not apply to HMO and PRO appeal determinations.
A party can initiate an appeal of a determination by an HMO under 42
CFR 417.616 and a determination by a PRO under 42 CFR 473.18(a).
The July 10, 1995 rule proposed to limit electronic requests for
review to those entities that electronically bill
[[Page 52666]]
their claims to a carrier system that has the capability to receive
claims electronically and, therefore, would also be able to receive
electronic requests for review.
We also proposed to change the current appeal period of 6 months to
180 days and to further provide a 150-day appeal period for telephone
requests for review within that 180-day period. We made this proposal
to allow an additional 30 days for the appellant to submit a written
request for review in the event they were unable to reach the carrier
by telephone.
The proposed rule also gave an overview of how we expected the
telephone and electronic process to work.
III. Analysis of and Responses to Public Comments
In response to the July 10, 1995 proposed rule, we received 14
timely items of correspondence. The majority of the commenters
supported our efforts to improve and expedite the review and appeals
process. Six of the 14 comments received concerned, in part, the
electronic request aspects of the proposed regulation. Since issuing
the proposed rule, we have determined that technical circumstances
beyond our control will not permit us to offer the option of
electronically requesting reviews of initial claims determinations, and
we are, therefore, withdrawing that provision of the proposed rule. In
the future, however, we may consider offering providers, physicians,
and suppliers the option of requesting a review of their intitial
determnation electronically. In order to offer this option we would
need to obtain an approved appeals data set from the ANSI X12 Committee
which then would need to be adopted by the DHHS as a HIPAA data
sandard. We are soliciting comments on the feasibility and benefit of
providing this option. We would also like to know any cost you believe
you would incur to use this option.
We are not responding in detail to specific comments relating to
the electronic requests. However, we provide the following overview of
those comments and our general response. Two commenters specifically
supported our desire to offer this option. One commenter suggested that
we should wait until the Medicare Transaction System comes online
before making this option available. As noted, we are not offering this
option due to technical circumstances beyond our control. There were
three technical comments. One comment concerned the cost of processing
electronic requests. The second comment concerned protecting the
privacy of the beneficiary. The third comment concerned the complexity
of handling non-assigned claims electronically.
With respect to the first comment, since we proposed to offer that
option only to those providers that bill electronically and only where
the carriers could receive and process claims electronically, there
would have been no additional costs to the supplier, provider, or
carrier. With respect to the second comment, we would protect the
privacy of the beneficiary by maintaining the requirement to have
either a letter signed by the beneficiary naming a representative, or
an Appointment of Representative form signed by the beneficiary to be
received by the carrier before any information could be released to
someone other than that beneficiary. Finally, the same document used to
verify assignment would have been required to be delivered to the
carrier by courier, by mail, or by facsimile before any non-assigned
claim would have been processed and before any Medicare payment would
have been released.
The following is a summary of those comments received pertaining to
telephone requests for reviews of initial claims determinations and our
response.
Comment: One commenter questioned whether the rule included the
Part B review process for Part A intermediaries.
Response: Yes, it does. For the purposes of 42 CFR part 405,
Subpart H, the term ``carrier'' also refers to an ``intermediary'' that
has entered into a contract with the Secretary under section 1816 of
the Social Security Act (the Act) and is authorized to make
determinations with respect to Part B provider or supplier services.
Comment: One commenter stated that currently HCFA determines the
timeliness of filing a request for a Part B review by the postmark on
the envelope of the written request and asked if timeliness of filing
requests by telephone would be determined by a telephone log.
Response: Carriers may record requests for reviews received by
telephone either in a manual log or in a computer database. The record
will show the date of the incoming request and other pertinent
information. The log date will be used to record whether the request
was received within the 6-month period, and will show how long it took
the carrier to complete the appeal.
Comment: One commenter recommended that the percentage of calls
monitored be set at the carrier's discretion instead of the 10 to 15
percent level indicated in the proposed MCM instructions addressing
this final rule that have been circulated to carriers.
Response: Issues dealing with how carriers will monitor telephone
calls and what percentage of calls will be monitored each month will be
included in forthcoming MCM instructions. When we issue the MCM
instructions for the telephone review process, they will state the
percentage of calls that must be monitored each month.
Comment: One commenter asked if we could outline what is considered
a reasonable timeframe for the processing of an appeal.
Response: In many cases, telephone reviews will be handled at the
time of the call. Some carriers do not have dedicated lines for
telephone reviews. In these cases, when the parties call in, someone
will take the information from the caller, then pass that information
to the section that will return the call. When possible, the review
will be performed at that time. When the telephone reviews are not
handled during the initial call, we expect the return call to be
processed within approximately 1 to 2 business days from the time of
the initial call.
Comment: Several commenters asked if specific contractor
performance evaluation (CPE) standards will be issued.
Response: We expect to establish CPE standards for telephone
reviews. These standards will be included in the MCM instructions that
will be issued at a later date.
Comment: One commenter asked how we will preserve confidentiality.
Another asked, more specifically, how we will prevent someone who does
not represent the provider from requesting a review.
Response: Carriers will be required to train their telephone
reviewers to meet the requirements of the Privacy Act. For calls from
individuals who purport to be the beneficiary involved or someone
representing the beneficiary, each caller will be asked to verify his
or her identity and, if necessary, his or her relationship to the
beneficiary. An Appointment of Representative form or a signed letter
from the beneficiary will be required when a caller purports to
represent the beneficiary. For calls from practitioners or other
suppliers regarding assigned claims, the carrier will verify the tax
identification number, name, and telephone number. The carrier will
give information only pertaining to the assigned claims of those
practitioners or suppliers. On nonassigned claims, the only information
the carrier will provide to
[[Page 52667]]
the physician or other supplier is the date the claim was processed,
unless the physician or supplier can provide the carrier with a
facsimile of a signed copy of the Appointment of Representative form or
a copy of a letter signed by the beneficiary. Regarding the issue of
preventing someone who does not represent the provider from making a
request for review, other individuals may request a review on behalf of
an appellant. The results of that review, however, will only be given
to the party enrolled under Part B, their assignee, other entities
having a standing to appeal the determination in question, or any
individual appointed as his or her representative (unless the
individual is disqualified or suspended from acting as a
representative).
Comment: One commenter asked if the Appointment of Representative
and Waiver of Right of Payment forms will be eliminated.
Response: We do not anticipate that the Appointment of
Representative and Waiver of Right of Payment forms will be eliminated.
Comment: One commenter asked whether all providers and suppliers
have the option of using telephone review procedures, or only those
providers and suppliers who accept Medicare assignment.
Response: Normally, telephone reviews will be available only to
providers and suppliers who accept assignment. That is, telephone
reviews are limited to providers and suppliers on assigned claims,
unless the beneficiary gives a nonparticipating supplier the right to
represent him or her and the nonparticipating supplier provides the
carrier with a signed copy of the Appointment of Representative form or
a signed letter from the beneficiary designating the nonparticipating
supplier to pursue the claim on behalf of the beneficiary. In those
instances in which a nonparticipating supplier is required to refund
any collected amount to the beneficiary in accordance with section
1842(l)(1)(A) of the Act, that supplier would have its own appeal
rights. Otherwise, carriers may take information from nonparticipating
suppliers, but cannot give any information concerning the result of the
review to that caller.
Comment: One commenter asked whether the rule will require that the
party who answers the telephone for the carrier be the primary receiver
of calls and if that party will be required to give his or her name, if
asked.
Response: Some carriers do not have dedicated lines for telephone
reviews. In those instances, the party who answers the telephone call
may only be obtaining certain information from the appellant (for
example, completing a form) and then will forward the form to the party
who will evaluate whether the request can be handled as a telephone
review. If so, the reviewer will telephone the appellant and perform
the review. We will also instruct the carriers to train their personnel
to give their names to the callers, if asked. In addition, we will
instruct the carriers that if the caller is requesting a telephone
review, and the carrier verifies that the request is a request for a
review, a confirmation number must be provided to the appellant at the
end of the telephone call. Furthermore, we will instruct the carriers
that their systems must record the date the appellant called as the
date of the request for a review. Having the system annotate the date
of the request and providing the appellant with a confirmation number
will protect the appellant's appeal rights.
Comment: One commenter recommended that beneficiary eligibility
and/or entitlement not be considered appropriate for telephone reviews.
The commenter was also concerned that allowing beneficiaries access to
the telephone review process will not be cost-effective since in most
cases the beneficiary will not have the information needed for the
review to be performed at the time of the review request.
Response: SSA handles all eligibility and/or entitlement issues.
The only entitlement issue that a Medicare carrier could handle during
a telephone review would be to advise the appellant that, as of a given
date, the records show that he or she does not have entitlement. The
forthcoming MCM instructions will list those issues we expect all
carriers to be able to resolve during a telephone review. We believe
that offering telephone reviews to beneficiaries will enhance customer
service to the beneficiary community. Even if the review cannot be
performed at the time that the telephone request is made, it is an
opportunity for the carrier to explain to the beneficiary how the
original claim was processed. Furthermore, we believe that with the
information available to the carrier in its computer database, it will
be able to effectively process many of the beneficiary requests for
review.
Comment: Several commenters asked if the MCM instructions will
impose a limit on the number of claims and reviews providers and
suppliers could request for review by telephone.
Response: Carriers will be allowed to determine how many claims per
review they can handle during each call. We anticipate that the
carriers will evaluate their workloads and staffing to determine the
number of claims their staff can handle. This self-imposed limit should
restrict the time involved for each call and, as a result, give more
appellants an opportunity to use the telephone review process.
Comment: One commenter asked if carriers should be required to have
sufficient capacity to receive a reasonable volume of telephone review
requests.
Response: As stated earlier, we will allow the carriers to
determine the number of claims that they are able to handle on each
call they receive so that the self-imposed limit will allow everyone to
request a review by telephone. We, therefore, expect carriers to have
sufficient staff to receive telephone requests for review. However, if
we determine that there is a need for additional resources, some
adjustments will be made. In addition, all parties will be informed
about the telephone review process in advance to enable them to make
effective use of this option.
Comment: One commenter questioned whether we intend for the carrier
representative who receives a telephone request for an appeal to merely
register the request, with the review itself occurring at a later date,
or to actually conduct the review at the time of the call.
Response: As stated earlier, we expect many carriers will perform
the review at the time of the initial call. There may be some carriers
that do not have dedicated lines for telephone reviews. In those cases,
parties will be informed in advance as to how that carrier will perform
the telephone review.
Comment: One commenter asked that the secondary claim review (the
commenter is referring to the first level of the appeal process) be
performed by someone other than the party who made the initial
determination.
Response: The original claim receives an initial determination. The
initial determination is the first determination made by a carrier or
intermediary following a request for Medicare payment for Part B claims
under title XVIII of the Act. The notice of the initial determination
informs each party of the determination and provides appropriate
appeals information to the parties having standing to appeal. The first
level of the Part B appeal is an independent review of the claim that
is performed by someone other than the party who made the initial
determination in accordance with current MCM instructions.
[[Page 52668]]
Comment: One commenter asked if we could modify existing Medicare
regulations to require that the review be conducted by a ``qualified
physician.''
Response: Reviews are conducted by contractor personnel who have
expertise in resolving claims disputes. A physician may be consulted in
an individual case. However, carriers do not normally employ physicians
to conduct reviews because it is not cost-effective.
Comment: One commenter asked if we will establish a mechanism to
guarantee that appellants initiating a telephone request for review are
able to reach the carrier.
Response: This rule will require all carriers to implement a
process by which they can receive telephone requests for review. We
will require all carriers to ensure that they have sufficient staff to
accommodate the number of calls they receive. If at any time it is
determined that this is not the case, we expect the carrier to re-
evaluate its process and take the necessary action to correct the
deficiency.
Comment: One commenter expressed concern that if appellants are not
limited by the number of appeals they can request per call, additional
resources (such as a 24-hour appeals hotline) or additional staff
should be provided.
Response: The forthcoming MCM telephone review instructions will
give the carriers some instructions to guide them in determining how
many claims can be appealed per call. The carrier will have to give
some consideration to whether the actual appeal will take place during
the initial call or whether the initial call will only be used to
gather information and the appeal will be handled at a later time.
Another issue that the carriers will have to consider is whether to set
a limit on the number of appeals allowed per call or a time limit per
call. We will not instruct the carriers to set a time limit, as this
might be construed as limiting the party's right to a full review of
his or her concerns. The carriers will inform the party in advance what
the requirements or limitations are for requesting a review via
telephone, as well as any limitations in those instances where the
review is performed during the initial call. The carriers will inform
the beneficiaries, providers, and suppliers via newsletters, stuffers,
seminars, customer service representatives, beneficiary and physician
advocacy groups, and others how the telephone process will work.
Comment: Several commenters asked about the specific documentation
requirements.
Response: The information the carrier receives during the telephone
review must be either: (1) documented on a review documentation form,
or (2) logged and maintained on a computer system so that the
information about the claim and request for review can be retrieved on
an on-line basis. All documentation must be assigned a review control
number (this can also be the confirmation number given to the appellant
at the end of the review). The confirmation number that the carriers
are required to provide an appellant can be their internal control
number, correspondence number, or document control number. The carrier
must be able to use the number to confirm the date of the appellant's
call. Other documentation requirements will be established in the
forthcoming MCM instructions.
Comment: One commenter stated that the rule does not indicate that
reopening of initial claim determinations, as permitted under
Sec. 405.841, can be done by telephone appeals.
Response: This rule does not permit parties to request reopenings
by telephone.
Comment: One commenter was concerned that, because carriers could
be overwhelmed with requests for review sent in by facsimile, the
option of submitting requests for review by facsimile should not be
advertised.
Response: This rule does not permit parties to request reviews by
facsimile. However, carriers may use facsimile machines to obtain
additional documentation from an appellant or the appellant's
representative. For example, carriers may use facsimile machines to
obtain a copy of the Appointment of Representative form or other
documentation.
Comment: One commenter asked whether, if the reviewer determines
that additional written information is needed to complete the review,
carriers have the option to suspend the review until that information
is received.
Response: In those cases in which the provider or supplier needs to
submit additional medical documentation and the information can be
supplied (for example, by facsimile) during the telephone review, or
within 24 hours of the telephone call, the carrier may suspend the
telephone review. The carrier must inform the appellant that the
telephone review will not be considered complete until the appellant
provides the requested additional information. If the appellant is
unable to provide the additional information during the telephone
review, or within 24 hours of the telephone call, the carrier has the
option to suspend the telephone review. If the information is not
provided within the allowed time the carrier will conduct a written
review or allow the appellant to call the carrier back when the
additional information becomes available. In either situation, the
carrier must provide the appellant with a confirmation number. If the
appellant is a beneficiary who does not have the additional information
on hand or does not have easy access to a facsimile machine, the
carrier must advise the appellant that the request for review will be
handled as a written review. In this instance also, the carrier must
provide the appellant with a confirmation number.
Comment: Several commenters expressed concern about the feasibility
and fairness of the 150-day limit for making requests for telephone
reviews.
Response: In the proposed rule, we suggested establishing a 150-day
timeframe after the date of the notice of the carrier's initial
determination within which a party may request a telephone review, and
a 180-day period for requesting reviews in writing, rather than the 6-
month period currently allowed. The proposal was an attempt to give
appellants, who we thought may be unsuccessful in their efforts to
reach the carrier by telephone, an additional opportunity to initiate a
request in writing before the time to appeal expired. We now believe
that the proposed 150-day timeframe for requesting telephone reviews is
confusing and that two different timeframes would not be cost-
effective. Furthermore, based on a survey of our carriers regarding the
timeframe within which they have been able to receive requests for
review by telephone after they send out initial determinations, we
believe that parties will not have difficulty reaching the carrier by
telephone. Therefore, we will retain the currently-specified 6-month
timeframe to request reviews of initial claims, regardless of the
method used to make the request. We will instruct our carriers to
advise parties, through their bulletins, workshops, and seminars to not
wait until the last day of the 6-month period to request a review by
telephone.
Comment: Several commenters were concerned that including details
of the telephone review process on the Explanation of Medicare
Benefits/Medicare Summary Notice (EOMB/MSN) and Remittance Advice forms
will be confusing for the beneficiaries.
Response: Details about the telephone review process will not be
provided on the EOMB/MSN or Remittance Advice forms; that information
will be provided by other means, such as in newsletters,
[[Page 52669]]
seminars, and envelope stuffers. However, there will be a general
statement on the EOMB/MSN form that informs the appellant that he or
she can telephone the carrier to request a review.
Comment: One commenter was concerned that the requirement to advise
the appellant of further appeal rights was redundant.
Response: We disagree. At the end of the review, the appellant
should be given information about how to proceed in the event that he
or she is still dissatisfied.
Comment: One commenter recommended that, if the telephone review is
an affirmation, the review determination letter should be sent
(following the telephone review) only when requested by the appellant.
Response: Whenever a review occurs, our current regulation at 42
CFR 405.811 requires the carrier to send a written notice of the review
determination to a party that states the basis of the determination and
advises the party of his or her appeal rights to a carrier hearing when
the amount in controversy is $100 or more.
Comment: One commenter recommended that to ensure adequate notice
of these new procedures, the notice sent with the carrier's initial
determination should (in addition to those items noted in the proposed
rule) clearly state that: (1) electronic transmissions may be submitted
only by those who submit their claims electronically; (2) electronic
transmission does not include facsimile transmissions; (3) if a request
is made to an SSA or HCFA office (rather than to a carrier), the
request must still be made in writing; (4) the carrier will resolve as
many issues as possible during the telephone request, but parties have
the opportunity to submit supporting documents; and (5) parties may
request, and be granted, an extension of time for filing a review
request if good cause is established by the carrier.
Response: As stated earlier, we are withdrawing the option of
requesting reviews of initial claims determinations electronically
(comment numbers (1) and (2)). With respect to comment (3), carriers
will be required to describe the telephone review process to all
beneficiaries, providers, and suppliers at least 30 days before
implementation. We do not believe that it is necessary or cost-
effective to describe in detail the telephone review procedures every
time the carrier issues an initial determination. There are a number of
ways the carrier can inform parties about the telephone review process,
such as through bulletins, newsletters, beneficiary, provider, and
supplier outreach seminars and meetings, or through contractor customer
service and inquiry departments. The opportunity to submit supporting
documentation (comment (4)) and the request for an extension of time
for filing a review request (comment (5)) are covered by existing
regulations. If circumstances warrant, parties will be advised of their
opportunity to submit supporting documentation and be granted an
extension of time.
Comment: Several commenters were concerned that requiring carriers
to send a written response when they have reviewed a request and
decided to pay a claim in full is an additional requirement.
Response: As stated earlier, whenever a review occurs, our current
regulations at 42 CFR 405.811 require that a notice of review
determination be sent to a party that states the basis for the
determination and advises the party of his or her right to a carrier
hearing when the amount in controversy is $100 or more. If the decision
results in full payment, the EOMB/MSN or Remittance Advice notice is no
longer sufficient unless it contains the basis of the determination and
advises the party of his or her right to a carrier hearing.
Comment: One commenter asked if telephone inquiries would be
screened to determine whether the party is requesting a review or is
just requesting an explanation of the initial determination.
Response: The carriers will be required to train their customer
service representatives and telephone reviewers to ask specific
questions to determine whether the caller is only requesting an
explanation of the initial determination or is requesting a review.
Comment: One commenter was concerned that, since payments as the
result of a telephone review are not subject to the payment floor, the
provider or supplier will be successful in receiving payment for these
claims in less time than if they initially filed a correct claim.
Response: All payments are subject to the payment floor (the
required waiting period that must occur before payment can be made) and
cannot be paid before that time expires. This is true for initial
claims, as well as for adjustments made as a result of a review. The
waiting period for an electronic claim is 14 days after the claim is
received, and the waiting period for a paper claim is 27 days after the
claim is received. Therefore, a provider or supplier should not receive
payment sooner, as the result of a telephone review, than he or she
would have received payment for the initial claim; that is, either 14
days for an electronic claim or 27 days for a paper claim.
Comment: One commenter asked if our intent is to offer telephone
reviews and electronic reviews as an option, or if our intent is to
require telephone reviews and offer electronic reviews as an option.
Response: When this rule becomes effective, beneficiaries,
providers, and suppliers will have the option of requesting a review by
telephone or in writing. As stated earlier, we are withdrawing the
option of requesting reviews of initial claims determinations
electronically.
IV. Provisions of the Final Regulations
For the most part, this final rule reflects the provisions of the
July 1995 proposed rule, except that we are withdrawing our proposals
to allow a party to request a review of a carrier's Part B initial
claim determination by electronic transmission and we are withdrawing
the proposed 150-day time period for a party to request a telephone
review.
In addition to establishing the provisions of the proposed rule,
except as noted above, this final rule: (1) continues the 6-month time
period currently in regulations for requesting a review of a carrier's
initial claim determination; (2) revises Sec. 405.805 of the
regulations to make a technical correction by removing the reference to
subparagraph ``(b)'' after Sec. 405.802; and (3) revises Sec. 405.807
of the regulations for consistency with the wording in Sec. 405.821(a).
V. Regulatory Impact Statement
We have examined the impacts of this final rule as required by
Executive Order 12866 and the Regulatory Flexibility Act (RFA) (Public
Law 96-354). Executive Order 12866 directs agencies to assess all costs
and benefits of available regulatory alternatives and, when regulation
is necessary, to select regulatory approaches that maximize net
benefits (including potential economic, environmental, public health
and safety effects; distributive impacts; and equity). The RFA requires
agencies to analyze options for regulatory relief for small businesses.
For purposes of the RFA, carriers and beneficiaries are not considered
to be small entities. For purposes of the RFA, most hospitals, and most
other providers, physicians, and other health care suppliers are small
entities, either by nonprofit status or by having revenues of $5
million or less annually.
Under this final rule, beneficiaries, providers, and suppliers may
request a
[[Page 52670]]
review of an initial claim determination by telephone in addition to
the current writing procedure. A telephone 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 claim determination in accordance with
current MCM instructions. A telephone review is considered to be less
costly to all parties and is a more expeditious way of handling appeals
than a written review.
Also, section 1102(b)(2) of the Act requires us to prepare a
regulatory impact analysis for any final rule that 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 604 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 a
Metropolitan Statistical Area and has fewer than 50 beds.
We are not preparing analyses for either the RFA or section
1102(b)(2) of the Act because we have determined and certify that this
final rule will not have a significant economic impact on a substantial
number of small entities or a significant impact on the operations of a
substantial number of small rural hospitals.
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.
We have reviewed this notice under the threshold criteria of
Executive Order 12612, Federalism. We have determined that it does not
significantly affect the States rights, roles, and responsibilities.
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.
For the reasons set forth in the preamble, 42 CFR chapter IV is
amended as set forth below:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
Subpart H--Appeals Under the Medicare Part B Program
1. The authority citation for part 405, subpart H is revised to
read as follows:
Authority: Secs. 1102, 1842(b)(3)(C), 1869(b), and 1871 of the
Social Security Act (42 U.S.C. 1302, 1395u(b)(3)(C), 1395ff(b), and
1395hh).
2. Section 405.805 is revised to read as follows:
Sec. 405.805 Parties to the initial determination.
The parties to the initial determination (see Sec. 405.803) may be
any party described in Sec. 405.802.
3. Section 405.807 is revised to read as follows:
Sec. 405.807 Request for review of initial determination.
(a) General. A party to an initial determination by a carrier, that
is dissatisfied with the initial determination and wants to appeal the
matter, may request that the carrier review the determination. The
request for review by the party to an initial determination must
clearly indicate that he or she is dissatisfied with the initial
determination and wants to appeal the matter. The request for review
does not constitute a waiver of the party's right to a hearing (under
Sec. 405.815) after the review.
(b) Place and method of filing a request. A request by a party for
a carrier to review the initial determination may be made in one of the
following ways:
(1) In writing and filed at an office of the carrier, SSA, or HCFA.
(2) By telephone to the telephone number designated by the carrier
as the appropriate number for the receipt of requests for review.
(c) Time of filing request. (1) The carrier must provide a period
of 6 months after the date of the notice of the initial determination
within which the party to the initial determination may request a
review.
(2) The carrier may, upon request by the party, extend the period
for requesting the review of the initial determination.
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: October 6, 1998.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
Dated: February 22, 1999.
Donna E. Shalala,
Secretary.
Editorial Note: This document was received at the Office of the
Federal Register September 27, 1999.
[FR Doc. 99-25477 Filed 9-29-99; 8:45 am]
BILLING CODE 4120-01-P
