decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2003 / AB-03-052
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Article Overview
This Program Memorandum from CMS outlines how intermediaries and carriers should manage Medicare appeals workloads during FY 2003 when resources are limited. It covers workload prioritization, timeframes for different appeal types, handling of case files and effectuation steps, and provider/supplier education about documentation needs. The article is relevant to Medicare contractors, appeals staff, and coding/billing teams that need to understand operational guidance affecting appeal processing.
Why This Topic Matters
It helps Medicare contractors and related staff understand administrative expectations for appeal backlogs, processing timelines, and communication requirements during the specified fiscal year.
Article Sections
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Program Memorandum
Introductory administrative information for the memorandum, including issuing agencies, transmittal details, and effective dates.
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Standard Operating Procedures
General guidance on establishing internal procedures for managing appeals workloads when resources are limited.
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Execution of Workload Prioritization
Instructions related to workload prioritization planning, supplemental budget requests, and coordination with regional offices.
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Priority 1–8 Appeals Workload Priorities
Ordered categories of appeals and related workload activities that contractors are directed to handle.
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Written and Telephone Reviews (completed by intermediaries and carriers)
Processing and completion standards for review requests handled by intermediaries and carriers.
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HO Hearings (completed by intermediaries and carriers)
Timing standards and completion criteria for hearing officer hearings and related effectuation steps.
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Reconsiderations (completed by intermediaries)
Processing standards and closure criteria for reconsideration requests handled by intermediaries.
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Part A and Part B ALJ Hearings
Submission, processing, and effectuation guidance for administrative law judge hearing cases.
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Agency Referrals (formerly protests)
Requirements for forwarding certain ALJ decisions for agency referral and related documentation handling.
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DAB Decisions
Timeframes for effectuation of Departmental Appeals Board decisions.
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Responding to Requests for Case Files
Instructions for responding to requests for appeal case files, including reconstruction and jurisdiction issues.
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Provider/Supplier Education
Communication expectations for informing providers and suppliers about documentation-related delays in appeals processing.
What You Will Learn
- How CMS organized appeals workload priorities for FY 2003.
- What general timeframes were referenced for different Medicare appeals activities.
- How contractors were expected to manage case files, effectuation, and backlog situations.
- What provider and supplier notification expectations were included in the memorandum.
Who Should Read This
- Medicare intermediaries
- Medicare carriers
- CMS regional offices
- Appeals processing staff
- Provider and supplier billing offices
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