CMS Updates Manual and Releases MLN Matters Article Regarding Appeals of Claims Decisions

CMS recently issued a Medicare Learning Network (MLN) Matters article in connection with Change Request 11042 released on April 12, 2019 (the Change Request), which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 – Appeals of Claims Decisions).  The MLN Matters article is intended for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs).

The MLN Matters article highlights the Change Request’s policy updates and revisions to Publication 100-04, Chapter 29 – Appeals of Claims Decisions, including the following:

  • Section 240.1 (Good Cause) – MACs will document when the MAC finds good cause for late filing on the appeal decision letter or the appeal case file.
  • Section 240.4 (Good Cause – Administrative Relief Following a Disaster) – MACs will observe additional procedures for appeals when a natural or man-made disaster occurs. 
  • Section 270.1.2 (How to Make and Revoke an Appointment) – MACs will observe the amendments to accepted forms of signatures, which state that all signatures may be handwritten or electronic, digital, and/or digitized. 
  • Section 270.1.6 (Curing a Defective Appointment of Representative) – MACs will observe tolling of an adjudication timeframe when attempting to cure a defective appointment instrument. 
  • Section 270.1.7 (Incapacitation or Death of Beneficiary) – MACs will observe enhanced guidance to determine proper parties to appeals and must follow state law when determining proper parties to initial determinations and appeals.  Legal representatives of deceased beneficiaries can be proper parties to initial determinations and appeals.
  • The Change Request limits the scope of redetermination review in certain instances, such as redeterminations of “claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor.”
  • The Change Request also adds the terms “Medicare number,” “Medicare beneficiary identifier (MBI),” and “attorney adjudicator” to the glossary and includes “Medicare number” throughout the manual chapter, which incorporates both the Health Insurance Claim Number and the new non-SSN MBI.



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