Medicare’s new Part B Fee-For-Service appeal procedures went into effect Jan. 1, 2006. As part of the new procedures, physicians may now file Level II appeals with Q2Administrators, the first independent contractor named for reviewing physician appeals.
Q2Administrators is the Qualified Independent Contractor responsible for reviewing Part B and Durable Medical Equipment (DME) reconsideration requests. Q2A’s Ohio office processes Part B reconsiderations for the East region of the United States and the South Carolina office processes Part B reconsiderations for the West region as well as DME reconsiderations for the entire United States. Addresses and appeal filing instructions are available at www.q2a.com. An online search feature at this website also allows providers to confirm the date an appeal was received by Q2A, appeal status, and decision deadline.
Part A Level II appeals must be filed with First Coast Service Options for providers in the West jurisdiction or Maximus for those in the East jurisdiction. See www.fcso.com for jurisdiction information.
Under the new appeals regulation, QICs must ensure that medical necessity denials are reconsidered by a panel of “physicians or other appropriate health care professionals.” The panel must also include professionals qualified to assess the regulatory aspects of the claim. QIC review replaces the Part B Carrier Hearing in the Medicare fee-for-service appeal process.
CMS is hopeful that use of independent review organizations utilizing physician reviewers will increase confidence in the appeal process and even reduce the number of appeals taken to higher levels.
“We believe that the implementation of requirements that ensure appellants of both the fairness of the decision-making process and the accuracy and consistency of the decisions reached can eventually lead to measurable reductions in the need for the elevation of appeals to the slower, more costly levels of the appeals system (for example ALJ hearing and MAC or Federal court review),” states the appeal regulations interim rule published March 8, 2005.
Any QIC’s reconsideration decision must be based on clinical experience and medical, technical, and scientific evidence, to the extent applicable to the appeal. QIC’s are bound by National Coverage Determinations, CMS manuals and federal Medicare statutes and regulations. QIC must also give substantial deference to local medical review policies and local coverage determinations. However, QICs have some flexibility to not apply local carrier policies if an explanation is given in the decision.
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