Determinations; appeals234
Qualified independent contractors will review initial determinations as to whether an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury with respect to benefits under Part A or B and will base any decisions with respect to the reconsideration on applicable information, including the medical records of the individual involved and other medical, technical and scientific evidence.235 In making expedited reconsiderations, the qualified independent contract will solicit the views of the individual involved236 and will notify by telephone and in writing the individual and the provider of services and attending physician of the individual the results of the reconsideration.237
Each qualified independent contractor will maintain accurate records of each decision made in an electronic database238 in a manner that provides for identification of the specific claim that gave rise to appeals,239 situations suggesting the need for increased education for providers of services, physicians or suppliers,240 and situations suggesting the need for changes in national or local coverage determinations.241 The contractor will permit access to and use of any such information and records as the Secretary may require.242 Each contractor will annually submit to the Secretary these records for the previous year.243
At least once every five years, the Secretary will conduct a survey of a sample of individuals who have filed appeals of determinations to determine the satisfaction of such individuals with the process for appeals.244 The Secretary will submit a report to Congress describing the results of this survey. 245
Footnotes
- 234. Social Security Act § 1869, 42 U.S.C. 1395ff.
- 235. Social Security Act § 1869(c)(3)(B)(i), 42 U.S.C. 1395ff(c)(3)(B)(i).
- 236. Social Security Act § 1869(c)(3)(C)(iii)(II), 42 U.S.C. 1395ff(c)(3)(C)(iii)(II).
- 237. Social Security Act § 1869(c)(3)(C)(iii)(I), 42 U.S.C. 1395ff(c)(3)(C)(iii)(I).
- 238. Social Security Act § 1869(c)(3)(I)(ii), 42 U.S.C. 1395ff(c)(3)(I)(ii).
- 239. Social Security Act § 1869(c)(3)(I)(ii)(I), 42 U.S.C. 1395ff(c)(3)(I)(ii)(I).
- 240. Social Security Act § 1869(c)(3)(I)(ii)(II), 42 U.S.C. 1395ff(c)(3)(I)(ii)(II).
- 241. Social Security Act § 1869(c)(3)(I)(ii)(III), 42 U.S.C. 1395ff(c)(3)(I)(ii)(III).
- 242. Social Security Act § 1869(c)(3)(I)(i), 42 U.S.C. 1395ff(c)(3)(I)(i).
- 243. Social Security Act § 1869(c)(3)(I)(iii), 42 U.S.C. 1395ff(c)(3)(I)(i).
- 244. Social Security Act § 1869(e)(4)(B), 42 U.S.C. 1395ff(e)(4)(B).
- 245. Social Security Act § 1869(e)(4)(B), 42 U.S.C. 1395ff(e)(4)(B).
.png)