Tuesday, April 23, 2019

Quality to the Next Level


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Appeals Procedures

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1-875821818 - Thursday, May 16, 2013

Rationale for the Referral:  The ALJ erred in adjudicating the claims on the merits after a QIC’s dismissal of a request for reconsideration in violation of 42 C.F.R. § 405.1004(b). The ALJ also erred in construing Appellant’s request for ALJ review of a QIC’s dismissal as a request for escalation.

Referral Document

Appeals Council Decision

 
1-920230641 - Monday, April 1, 2013
Rationale for the Referral: A physician’s effective date of enrollment is not an initial determination and therefore not appealable under § 1869 of the Social Security Act.

Referral Document

Appeals Council Decision
 
1-908705768 - Friday, February 22, 2013
Rationale for the Referral: Failing to include as a party a Medicare contractor that timely responded to the ALJ’s Notice of Hearing indicating its intention to participate in the ALJ hearing with party-status is an error of law.

Referral Document

Appeals Council Decision

 
1-820091481 - Tuesday, June 5, 2012
Rationale for the Referral: An ALJ’s jurisdiction is limited to reviewing claims that have been reviewed by the contractor and QIC.  An ALJ may not order prospective Medicare reimbursement for items or services that have not yet received an initial determination, redetermination and reconsideration.

Referral Document

Appeals Council Decision


 
1-801055901 - Tuesday, November 22, 2011

Rationale for the Referral: The ALJ’s jurisdiction as to dates of service dismissed by the QIC is confined to the issue of whether the QIC erred in dismissing the request for reconsideration. If the ALJ decides the QIC’s dismissal is in error, the ALJ must remand those claims to the QIC for reconsideration.

Referral Document

Appeals Council Decision

 
  
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