Last Modified: 9/23/2020
Business: Part A
Q: Are claims denied by other medical review contractors, such as the Comprehensive Error Rate Testing program (CERT) and Recovery Audit Contractor (RAC), eligible for the Part A East (PAE) Qualified Independent Contractor (QIC) appeals demonstration?
A: Yes, as long as the other contractor “review or audit” is over, and a redetermination (the first level of appeal) was found unfavorable, the claim can be appealed to the second level or reconsideration by the QIC.
Reconsiderations for service termination, hospital discharge reviews, or providers that are already involved in another Centers for Medicare & Medicaid Services (CMS) initiative such as the settlement conference facilitation (SCF) or the low volume appeals (LVA) are not eligible for telephone discussions and/or reopenings under the demonstration. These CMS initiatives would take precedence over the demonstration reopening process. However, appeals filed as a result of denials by the CERT and RAC may be part of the PAE QIC appeals demonstration after the redetermination level.
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