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May 15, 2023

Reminders on Good Cause Rights When Filing Appeals During the PHE

Effective for dates of service on and after May 12, 2023, the PHE has ended.

When the COVID-19 PHE ends, these flexibilities will continue to apply consistent with existing authority and requests for appeals must meet the existing regulatory requirements.

CGS wants to remind suppliers of important information when filing appeals during the public health emergency (PHE).

Specifically, please note that you must state a reason for a late appeal request. There is not an assumption that the PHE impacted all suppliers.

For more details, read the information below from the IOM Publication 100-04, Chapter 29, Section 240.4, Good Cause – Administrative Relief Following a DisasterExternal Website:

  1. Definition of Disaster
    A disaster is defined as any natural or man-made catastrophe (such as hurricane, tornado, earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, fire, flood, or explosion) which causes damage of sufficient severity and magnitude to partially or completely destroy medical records and associated documentation that could be needed and/or requested by the MACs in the course of the adjudication process, interrupts normal mail service (including US Postal delivery, overnight parcel delivery services, etc.), impacts ability to file appeals in a timely manner, and/or otherwise significantly limit the provider’s/supplier's daily operations.

    A disaster may be widespread and impact multiple structures (e.g., a regional flood) or isolated and impact a single site only (e.g., water main failure). The fact that a provider/supplier is located in a presidentially declared disaster area under the power of the Stafford Act is not sufficient in itself to justify administrative relief, as not all structures in the disaster area may have been subject to the same amount of damage. Damage must be of sufficient severity and extent to compromise retrieval of medical records. The provider/supplier needs to state that they were impacted by the disaster.

  2. Basis for Providing Administrative Relief
    In the event of a disaster, MACs shall grant temporary administrative relief to any affected providers and suppliers for up to 6 months (or longer with good cause). Administrative relief is to be granted to providers/suppliers/beneficiaries on a case-by-case basis in accordance with the following guidelines:

    1. Situation: A provider/supplier/beneficiary in the affected area needs an extension to file a request for an appeal.

      Action: The MAC shall grant an extension to request an appeal under the good cause exception. Please see 42 CFR § 405.942. If the request is related to an overpayment, the MAC shall accept the request and stop recoupment immediately.

    2. Situation: The MAC has requested or needs to request additional documentation for a pending appeal, but the provider/supplier/beneficiary has been impacted by a disaster.

      Action: The MAC shall hold the request until the documentation can be obtained or submitted. However, to the extent that the contractor can use other data sources that are available to substantiate payment for the claim, it should do so. The CMS will waive the timeliness requirements for processing these appeals.

    3. Situation: A request for an appeal filed by an appointed representative on behalf of a party contains a missing or defective appointment instrument and the party is in the affected area.

      Action: The contractor shall process the request and attempt to obtain the corrected appointment instrument. If the corrected appointment instrument is not received by the end of the appeals adjudication period, contractors shall send the redetermination decision letter to the appellant party and any other party to the appeal, but not to the individual attempting to act as the representative.

    4. Situation: A MAC receives a request for redetermination from a provider/supplier/beneficiary in the affected area and the request is missing some of the required elements to make it a valid request. However, the MAC has information in the shared systems that would allow it to identify the missing element(s).

      Action: The MAC shall accept and process the request, using information already available to it via the shared system.

  3. Verification
    In the case of complete destruction of medical records where no backup records exist, MAC Appeal Units and QICs shall accept an attestation that no medical records exist and consider the services covered and correctly coded.

Publication History

June 9, 2021 Originally published
May 15, 2023 Added language about the end of the COVID-19 PHE


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