[Federal Register Volume 64, Number 205 (Monday, October 25, 1999)]
[Proposed Rules]
[Pages 57431-57436]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-27623]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Part 405
[HCFA-6003-P]
RIN 0938-AI49
Medicare Program; Appeals of Carrier Determinations That a
Supplier Fails to Meet the Requirements for Medicare Billing Privileges
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would extend appeal rights to all suppliers
whose enrollment applications for Medicare billing privileges are
disallowed by a carrier or whose Medicare billing privileges are
revoked, except for those suppliers covered under other existing
appeals provisions of our regulations. In addition, we propose to
revise certain appeal provisions to correspond with the existing appeal
provisions in those other sections of our regulations. We also would
extend appeal rights to all suppliers not covered by existing
regulations to ensure they have a full and fair opportunity to be
heard. Although we are not required by the Administrative Procedure Act
to publish this rule as a proposed rule (see 5 U.S.C. section
553(b)(3)(A), we are doing so in order to allow interested parties the
opportunity for prior notice and comment.
DATES: Written comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. Eastern
time on December 27, 1999.
ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-6003-P, P.O. Box 26688,
Baltimore, MD 21207-0488.
If you prefer, you may deliver your written comments (1 original
and 3 copies) to one of the following addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201-0001, or
Room C5-16-03, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code HCFA-6003-P. Written comments received timely will be
available for public inspection as they are received, generally
beginning approximately 3 weeks after publication of a document, in
Room 443-G of the Department's offices at 200 Independence Avenue, SW.,
Washington DC, on Monday through Friday of each week from 8:30 a.m. to
5 p.m. Eastern time (phone: (202) 690-7890).
FOR FURTHER INFORMATION CONTACT: Charles Waldhauser, (410) 786-6140.
SUPPLEMENTARY INFORMATION:
I. Background
A Medicare beneficiary generally may obtain covered Medicare
services from any person, agency or institution that is qualified to
participate in the Medicare program and that undertakes to furnish
those services. Various provisions of the statutes and regulations
establish conditions of participation or standards that a health care
supplier or provider must meet in order to receive Medicare payment.
These standards differ depending on the type of provider or supplier
involved and whether the services are furnished under parts A, B, or C
of the Medicare statute. There are also differences in qualifications
between providers and suppliers of services, and differences among the
various types of suppliers, in how they are enrolled in the Medicare
program. For some classifications of providers and suppliers, an on-
site survey is required. For other individuals or entities, a
determination can be made based largely on the information provided by
the applicant.
The Medicare regulations in Part 498 provide appeal rights for
certain suppliers that have been found to not meet certain conditions
of participation or established standards. For the purposes of part
498, these suppliers include independent laboratories; suppliers of
portable x-ray services; rural health clinics; federally qualified
health centers; ambulatory surgical centers; organ procurement
organizations; end-stage renal disease treatment facilities; and
chiropractors and physical therapists in independent practice.
In addition, our regulations at Sec. 405.874 provide an appeals
process for Durable Medical Equipment, Prosthetics and Orthotics and
Supplies (DMEPOS) suppliers that wish to contest a disallowance of an
application for a billing number or the revocation of an existing
billing number. The Sec. 405.874 appeals process afforded DMEPOS
suppliers includes the right to a carrier hearing before a carrier
official who was not involved in the original determination, and the
right to seek a review before a HCFA official designated by the HCFA
Administrator.
The purpose of this proposed rule would be to establish an
administrative appeals process for certain other suppliers, such as
physicians or physician assistants, who have had an application for
billing privileges disallowed or existing billing privileges revoked,
but who are not specifically included under either the Part 498 or
Sec. 405.874 appeals processes. Because the adverse determinations with
respect to these other suppliers are similar to those described above
for DMEPOS suppliers, we are proposing to amend the existing appeals
process at Sec. 405.874 to include appeal rights for these other
suppliers.
In December, 1998, we issued HCFA Ruling 98-1, regarding the
appeals process Medicare carriers must provide to physicians, non-
physician practitioners, and to certain entities that receive
reassigned benefits from physicians and non-physician practitioners.
HCFA Rulings are decisions of the Administrator that serve as precedent
final opinions and orders and statements of policy and interpretation.
They provide clarification and interpretation of complex or ambiguous
provisions of law or regulations relating to Medicare, Medicaid,
Utilization and Quality Control Peer Review, private health insurance,
and related matters. HCFA Rulings are binding on all HCFA components,
Medicare contractors, the Provider Reimbursement Review Board, the
Medicare Geographic Classification Review Board, the Departmental
Appeals Board, and Administrative Law Judges (ALJs) who hear Medicare
appeals. These Rulings promote consistency in interpretation of policy
and adjudication of disputes. This proposed rule is very similar to
HCFA Ruling 98-1, but expands the types of suppliers covered.
II. Provisions of the Proposed Rule
We are proposing to revise the scope of Sec. 405.874 (``Appeals of
carrier decisions that supplier standards are not met.'') to extend
appeal rights to all
[[Page 57432]]
suppliers whose enrollment applications for Medicare billing privileges
are disallowed or whose Medicare billing privileges are revoked, except
for those suppliers covered under the appeals provisions of Part 498.
These administrative appeal rights would now apply to suppliers of
durable medical equipment, prosthetics, orthotics, and supplies;
ambulance service providers; independent diagnostic testing facilities;
physicians; and other entities such as physician assistants.
We would also revise the existing procedures in Sec. 405.874. These
procedural changes would be as follows:
Carrier Time Limit to Process Enrollment Application
Currently, Sec. 405.874(a) provides that a carrier must accept or
reject an entity's enrollment application for a billing number or
request additional information within 15 days of the receipt of the
enrollment application. We believe the 15-day requirement restricts our
ability to properly evaluate enrollment applications. Although the
majority of supplier applicants to the Medicare program are legitimate,
our mandate to ensure the integrity of the Medicare program requires
stringent review of supplier enrollment applications, including
verifying information with outside agencies, for example State
licensing boards. These application verifications require additional
amounts of time, sometimes beyond the current 15-day period, and the
amount of time is not always predictable. In addition, such a
requirement is not germane to appeals provisions. Therefore, for the
proposed revision to Sec. 405.874(a), we would remove the 15-day
requirement. In order to ensure that time frames do not become
excessively burdensome to suppliers, we monitor the time required by
carriers to process enrollment applications as part of our oversight of
carrier operations. In addition, we are considering placing a
timeliness requirement for processing of applications for supplier
billing privileges in another part of our regulations.
Terminology
Current Sec. 405.874(b) provides that a carrier can disallow or
revoke an entity's request for a billing number but must notify the
supplier of its right to appeal. The supplier then has 90 days after
the postmark of the notice to request an appeal. For purposes of this
section and to parallel language used in other appeals provisions of
Part 405, in revised Sec. 405.874(a) and Sec. 405.874(b), we propose to
clarify the language concerning when a notice is received by the
supplier from ``postmark of the notice'' to ``the date of receipt of
the carrier's notice.'' We would specify that ``the date of receipt of
the notice'' is presumed to be five days after the date of the notice.
The burden would be on the supplier to show that more than five days
actually elapsed between the date of the notice and the date it
received the notice in order for the supplier to be granted relief from
the requirement to file an appeal within 65 days from the date of the
notice. In Sec. 405.874(b)(1), we would clarify also that a Medicare
billing number is the identification number of a provider or supplier
to which we have granted Medicare billing privileges.
Disallowances and Revocations
Current Sec. 405.874(b) discusses the procedures that carriers
follow in disallowing a request for a Medicare supplier billing number
and in revoking an enrolled supplier's Medicare billing number. We
would now set forth the procedures to be followed by carriers
concerning notifying a supplier of the disallowance of an enrollment
application for supplier billing privileges in the proposed revision to
Sec. 405.874(a) and the revocation of an already enrolled supplier's
billing number in the proposed revision to Sec. 405.874(b). We would
separate these procedures because we believe the prior language was not
sufficiently clear.
Also, existing Sec. 405.874(b) provides a 90-day time frame under
which a supplier may appeal a carrier's determination or a supplier or
carrier may appeal a carrier hearing officer's decision. We are
proposing the revision of the 90-day appeal period to a 60-day appeal
period in new paragraphs (a)(3), (b)(1)(iii), and (c)(3)(iii) in order
to expedite the proceedings and to parallel the standard time frames
for Medicare appellants who file Part A or Part B claim appeals with
administrative law judges. We believe 60 days is a sufficient amount of
time in which to file an appeal.
In the proposed revision to Sec. 405.874(b)(2), we would clarify
that a revocation of a supplier billing number that is based on a
Federal exclusion or debarment is effective with the effective date of
the exclusion or debarment, regardless of the date of the notice from
the carrier that the billing number is revoked. We would further
clarify in the proposed revision to Sec. 405.874(b)(3) that suppliers
are not paid for services or supplies furnished during a period in
which their supplier billing number has been revoked. With respect to
DMEPOS suppliers, section 1834(j)(1) of the Act states that, with the
exception of medical equipment and supplies furnished incident to a
physician's service, no payment may be made by Medicare for items and
supplies unless the supplier has a valid, active Medicare billing
number. Therefore, any expenses for items or supplies furnished to a
Medicare beneficiary on or after the effective date of the inactivation
(or revocation) of a DMEPOS supplier's billing number are the DMEPOS
supplier's responsibility. Unless the DMEPOS supplier has proof it
notified the beneficiary, in accordance with section 1834(a)(18)(A)(ii)
of the Act, that Medicare payment may not be made and that the
beneficiary agreed to take financial responsibility, the DMEPOS
supplier is responsible for the expenses incurred for the items and
services furnished. Without this proof of beneficiary notification and
agreement, the DMEPOS supplier is required to refund on a timely basis
to the beneficiary (and is liable to the beneficiary for) any amounts
collected from the beneficiary for items or services furnished during
the period of inactivation or revocation. If the DMEPOS supplier fails
to refund as required, sanctions such as civil money penalties,
assessments, and exclusions may be imposed. (See section 1879(h)(3) of
the Act). In contrast, other, non-DMEPOS suppliers, for example,
physicians, currently may bill for services furnished before they are
issued a supplier billing number, assuming they meet Medicare
requirements. We propose that claims submitted to carriers for services
or supplies furnished during a period of supplier ineligibility are to
be rejected by the carrier, not denied. Rejections of claims by
carriers are not appealable by suppliers.
Hearing by Carrier
In the proposed revision to Sec. 405.874(c)(1), we would change the
language in current Sec. 405.874(c) that requires a carrier hearing
officer to ``schedule a hearing to be held within one week,'' to
require that the hearing must be held within ``60 days of receipt of
the appeal request.'' The previous ``one week'' language was unclear as
to the intent--whether it was the ``scheduling'' or the ``hearing''
that was required within one week. We believe that it is unreasonable
to require that a hearing be scheduled or held within 1 week of
receiving the request for appeal. The carrier needs time to prepare the
case and forward it to the hearing officer. The person or entity
seeking review may also need more than one
[[Page 57433]]
week to prepare for the case. With respect to the time frame for
issuing hearing officer decisions, the new provision would parallel the
timeliness requirement in Sec. 405.834.
In addition, current Sec. 405.874(c) also discusses the procedures
to be followed in a carrier hearing in consideration of the
disallowance or revocation of a supplier billing number. In the
proposed revision to Sec. 405.874(c)(2), we would change the language
to clarify that the supplier is required to prove that it is in
compliance with all Medicare requirements for billing privileges, and
that the carrier incorrectly disallowed or revoked the supplier's
billing number. The ultimate burden of proof is on the supplier to show
that it meets all requirements upon application, and to show at any
time that it continues to meet any requirements that may be in place to
bill Medicare. It is presumed that the carrier made a reasonable
determination to disallow or revoke a supplier's billing number based
on information it had at the time of the decision. The supplier would
be required to furnish the evidence that clearly shows the
determination was in error at the time it was made.
In new Sec. 405.874(c)(3), we would revise the timeliness
requirement in current Sec. 405.874(c) for the hearing officer to issue
a decision from ``two weeks'' to ``as soon as practicable after the
hearing'' because the hearing officer must be allowed sufficient time
to adjudicate the facts and make a reasoned decision. In addition, the
proposed revision requirement would parallel the timeliness requirement
for other hearing officer decisions in part 405.
Implementation of Reversal of Carrier Determination
We propose to conclude our revision of current Sec. 405.874(c) by
adding paragraphs (5), (6), and (7) to allow carrier discretion in
deciding whether to put into effect a carrier hearing officer's
reversal of the carrier's determination to disallow or revoke a
supplier billing number, pending a possible appeal by the carrier. If
the carrier were to decide to appeal the carrier hearing officer's
decision to HCFA, the carrier would be permitted to continue to hold
the supplier billing number as disallowed or revoked, pending the HCFA
official's decision. The carrier would also have the discretion to
implement the reversal (that is, grant or reinstate billing privileges)
even though it is appealing the carrier hearing officer's decision. A
carrier would implement a reversal decision immediately if it decides
not to appeal the carrier hearing officer's decision to HCFA.
In the event that a supplier were to decide to appeal a carrier
hearing officer's partial reversal to HCFA, and the carrier were to
decide not to appeal, the carrier would implement the partial reversal.
A partial reversal could be, for example, a decision to reinstate a
revoked billing number, but not back to the date of the revocation;
thus, there would be a period of non-eligibility for the supplier from
the date of revocation to the reinstatement date. If the supplier were
to appeal to the HCFA official to be reinstated for full eligibility,
and the carrier were to decide not to appeal, the carrier would still
implement only the partial reinstatement until the HCFA official would
issue a decision on the appeal for full reinstatement.
Hearing by HCFA
In the proposed revision to Sec. 405.874(d), we would change the
language that currently appears in Sec. 405.874(d) to specify that the
HCFA official bases his or her decision on the carrier hearing
officer's decision and the case file (record) established by the
carrier hearing officer. In other words, this is not a de novo hearing.
However, the HCFA official would be permitted to supplement the record
as deemed necessary to clarify any issues. The HCFA official would
issue a decision as soon as practicable in light of the issues involved
and his or her workload. The HCFA official's decision would be the last
administrative process available to either the carrier or the supplier.
Reversal of Carrier Determination
We would revise current Sec. 405.874(e) to clarify that we will not
pay for services furnished by suppliers during a period in which the
supplier's billing privileges have been revoked. Therefore, any
reversals of carrier decisions must indicate the effective date of the
reversal. No appeal rights for suppliers accrue to rejections of claims
or parts of claims that were made because the services or items were
furnished during a period of supplier ineligibility. Claims for items
or services furnished during a period for which the supplier's
eligibility is established upon reversal would be adjudicated by the
carrier in accordance with normal procedures, and would be denied or
approved on their own merits.
Reinstatement of Supplier Billing Number Following Corrective Action
Current Sec. 405.874(f) addresses corrective action plans. We would
revise this paragraph to clarify that the supplier must be in
compliance with all requirements in order to have its billing number
reinstated, and that we must be satisfied that the supplier is in
compliance and will remain in compliance. The burden of proof again
would be on the supplier to demonstrate that it can operate in
accordance with Medicare requirements. It would not be enough for the
supplier to submit a plan for corrective action. If we were to decide
to reinstate a billing number, we would establish the date of
reinstatement, and the carrier would be able to pay for services
furnished on or after the effective date of reinstatement.
Reopening of Carrier Determination, Carrier Hearing Officer Decision,
or HCFA Decision
We propose to add new Sec. 405.874(g) to permit the carrier,
carrier hearing officer, or HCFA official to reopen and revise its
determination or decision in accordance with Secs. 405.841 and 405.842.
This means, for example, that the carrier would not be permitted to
revise a carrier hearing officer's or HCFA official's decision.
Effective Date for DMEPOS Supplier Billing Number
We propose to add new Sec. 405.874(h), wherein we would address the
situation that a DMEPOS supplier may not be paid for items or services
furnished prior to the date its billing number is issued. Any decision
to change, either through appeal or reopening, a disallowance of an
enrollment application would establish the effective date of the
billing number. Any claims for services or items furnished prior to the
effective date of the billing number would be rejected and no appeal
rights would apply for those claims--see Sec. 405.803. Further,
sections 1834(a)(18)(A)(ii) and 1834(j)(4) of the Act apply to those
claims and provide that no payment may be made, and that the supplier
may not charge the beneficiary, for services furnished prior to the
effective date, unless the beneficiary explicitly agreed to pay even
though Medicare would not pay.
Submission of Claims
Finally, we would add new Sec. 405.874(i) to describe the procedure
for submitting claims after a reversal of a supplier enrollment
application disallowance or billing number revocation, or after a
billing number reinstatement. We would specify that if a supplier is
reinstated, any claims for items or services, furnished during the
period of supplier ineligibility that became a period of eligibility
upon reinstatement, may be submitted for adjudication as long as the
period for
[[Page 57434]]
filing claims has not elapsed. If the claims previously were filed
timely but were rejected, they would be considered filed timely upon
resubmission.
III. Regulatory Impact Statement
We have examined the impact of this proposed rule under Executive
Order 12866 and the Regulatory Flexibility Act (RFA) (Pub. L. 96-354).
Executive Order 12866 directs agencies to assess all costs and benefits
of available regulatory alternatives and, when regulation is necessary,
to select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety effects;
distributive impacts; and equity). The RFA requires agencies to analyze
options for regulatory relief for small businesses. For purposes of the
RFA, most hospitals, and most other providers, physicians, and health
care suppliers are small entities, either by nonprofit status or by
having revenues of $5 million or less annually.
According to data submitted to us by carriers in calendar year
1997, 129,000 enrollment applications were submitted to the Medicare
carriers by suppliers seeking to receive billing privileges. We believe
that a vast majority of these applicants were small businesses. Of
those applications, 2,310 were denied. A total of 291 applicants
requested an appeal of their denial.
Also, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any proposed rule that may have a
significant impact on the operations of a substantial number of small
rural hospitals. That analysis must conform to the provisions of
section 604 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital that is located outside of
a Metropolitan Statistical Area and has fewer than 50 beds.
We are not preparing analyses for either the RFA or section 1102(b)
of the Act because we have determined, and we certify, that this
proposed rule will not have a significant economic impact on a
substantial number of small entities or a significant impact on the
operations of a substantial number of small rural hospitals. As
discussed in detail, under section II., Provisions of the Proposed
Rule, the purpose of the proposed changes to our current regulations
would be to extend appeal rights to all suppliers whose enrollment
applications for Medicare billing privileges are disallowed or whose
Medicare billing privileges are revoked, except for those suppliers
covered under the appeals provisions of part 498.
We believe that this proposed rule would have no adverse impact on
small entities; in fact, it would afford small suppliers a measure of
protection against adverse actions by HCFA, and extend protection to a
larger group of suppliers beyond the DMEPOS suppliers currently covered
under Sec. 405.874. Because this proposed rule would merely clarify,
expand, and update our current policy and administrative appeal rights,
we anticipate slight, if any, economic impact on small entities. We
are, however, inviting comments as to whether this rule would have a
significant impact on a substantial number of small rural hospitals or
entities.
IV. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, when we issue the final rule, we will
respond to the comments in the preamble to that document.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995 (PRA), agencies are
required to provide a 60-day notice in the Federal Register and solicit
public comment before a collection of information requirement is
submitted to the Office of Management and Budget (OMB) for review and
approval. In order to fairly evaluate whether an information collection
should be approved by OMB, section 3506(c)(2)(A) of the PRA requires
that we solicit comment on the following issues:
Whether the information collection is necessary and useful
to carry out the proper functions of the agency;
The accuracy of the agency's estimate of the information
collection burden;
The quality, utility, and clarity of the information to be
collected; and
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
However, we believe the information collection activities
referenced in Sec. 405.874 are exempt under the terms of the PRA for
the following reasons:
As defined in 5 CFR 1320.4, information collections
conducted or sponsored during the conduct of criminal or civil action,
or during the conduct of an administrative action, investigation, or
audit involving an agency against specific individuals or entities are
exempt from the PRA;
As described in 5 CFR 1320.3(h)(9), facts or opinions
obtained or solicited through nonstandardized follow-up questions
designed to clarify responses to approved collections, are exempt from
the PRA; and/or
Nonstandardized information collections directed to less
than ten persons do not constitute information collections as outlined
in 5 CFR 1320.3(c).
Since we believe that the collection requirements are either part
of the administrative, audit and/or adjudicatory process, collected in
a nonstandardized manner, and/or collected from less than ten persons,
they fall under these exceptions.
If you comment on any of these information collection and
recordkeeping requirements, please mail copies directly to the
following:
Health Care Financing Administration, Office of Information Services,
Information Technology Investment Management Group, Division of HCFA
Enterprise Standards, Room C2-26-17, 7500 Security Boulevard,
Baltimore, MD 21244-1850. Attn.: John Burke, HCFA-1907-P
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
20503. Attn.: Allison Herron Eydt, HCFA Desk Officer
List of Subjects in 42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
42 CFR Chapter IV would be amended as set forth below:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
Subpart H--Appeals Under the Medicare Part B Program
1. The authority citation for part 405, subpart H, continues to
read as follows:
Authority: Secs. 1102, 1842(b)(3)(C), and 1869(b) of the Social
Security Act (42 U.S.C. 1302, 1395u(b)(3)(C), and 1395ff(b)).
2. Section 405.874 is revised to read as follows:
[[Page 57435]]
Sec. 405.874 Appeals of carrier determinations that a supplier fails
to meet the requirements for Medicare billing privileges.
(a) Disallowance of supplier enrollment application. If a carrier
disallows a supplier's enrollment application, the carrier must notify
the supplier by certified mail. The notice must include the following:
(1) The reason for the disallowance.
(2) The right to appeal.
(3) The date by which the supplier must file the appeal, that is,
60 days after the date of receipt of the carrier's notice. (The date of
receipt of the carrier's notice is presumed to be 5 days after the date
of the notice.)
(4) The address to which the written appeal must be mailed.
(b) Revocation of Medicare billing number--(1) Notice of
revocation. If a carrier revokes a supplier's Medicare billing number,
that is the identification number of a provider or supplier to which
HCFA has granted Medicare billing privileges, the carrier must notify
the supplier by certified mail. The notice must include the following:
(i) The reason for the revocation.
(ii) The right to appeal.
(iii) The date by which the supplier must file that appeal, that
is, 60 days after the date of receipt of the carrier's notice. (The
date of receipt of the carrier's notice is presumed to be 5 days after
the date of the notice.)
(iv) The address to which the written appeal must be mailed.
(2) Effective date. Revocation of a supplier billing number is
effective 15 days after the carrier mails the notice of its
determination to the supplier. A revocation based on a Federal
exclusion or debarment is effective with the date of the exclusion or
debarment.
(3) Payment. Carriers do not pay for services furnished by the
supplier beginning with the effective date of a revocation. Claims for
services furnished to Medicare beneficiaries after the effective date
of the revocation are rejected. Rejections of claims because a supplier
does not have a valid billing number may not be appealed by the
supplier. If the supplier is successful in overturning a revocation,
rejected claims for services that were furnished during the overturned
period of revocation may be resubmitted. (See paragraph (i) of this
section).
(c) Hearing by carrier. (1) For suppliers, other than those whose
appeal rights are defined in part 498 of this chapter, a carrier
hearing officer, not involved in the original determination to disallow
a supplier's enrollment application, or to revoke a current billing
number, must hold a hearing within 60 days of receipt of the appeal
request, or later if requested by the supplier.
(2) Both the supplier and the carrier may offer new evidence. The
ultimate burden of proof is on the supplier to show that its enrollment
application was incorrectly disallowed or that the revocation of its
billing number was incorrect.
(3) The hearing officer issues a written decision as soon as
practicable after the hearing and forwards the decision by certified
mail to HCFA, the carrier, and the supplier. This decision includes the
following:
(i) Information about the carrier's and supplier's further right to
appeal.
(ii) The address to which the written appeal must be mailed.
(iii) The date by which the appeal must be filed, that is, 60 days
after the date of receipt of the notice. (The date of receipt of the
carrier's notice is presumed to be 5 days after the date of the
notice.)
(4) Either the carrier or supplier may appeal the carrier hearing
officer's decision to HCFA.
(5) A carrier hearing officer's partial or complete reversal of a
carrier's determination is not implemented pending the carrier's
decision to appeal the reversal to HCFA, unless the carrier, in its
sole discretion, and without prejudice to its right to appeal, decides
to implement the reversal pending an appeal.
(6) The carrier implements a reversal if it decides not to appeal a
reversal to HCFA, or the time to appeal expires.
(7) A carrier may implement a carrier hearing officer's partial
reversal even if the supplier has appealed the partial reversal to
HCFA, or the time for the supplier to file an appeal has not expired.
(d) Hearing by HCFA. A HCFA official, designated by the
Administrator of HCFA, issues a decision based on the decision and the
record established by the carrier hearing officer. The HCFA official
may supplement the record by requesting and obtaining any additional
information from the carrier or the supplier. The HCFA official's
decision--
(1) Is issued in writing as soon as practicable after the HCFA
official determines that there is sufficient information to decide the
appeal (or that no additional information is forthcoming), unless the
party appealing the hearing officer's decision requests a delay;
(2) Is forwarded by certified mail to both the carrier and the
supplier; and
(3) Contains information that no further administrative appeals are
available.
(e) Impact of reversal of carrier determination on claims
processing. If a revocation of a supplier billing number is reversed
upon appeal, the appeal decision establishes the date the reinstated
supplier number is effective. Claims for services furnished to Medicare
beneficiaries during a period in which the supplier billing number was
not effective are rejected. If a supplier is determined not to have
qualified for a billing number in one period but qualified in another,
carriers process claims for services furnished to beneficiaries during
the period for which the supplier was Medicare-qualified. Subpart C of
this part sets forth the requirements for recovery of overpayments.
(f) Reinstatement of supplier billing number following corrective
action. If a supplier completes a corrective action and provides
sufficient evidence to the carrier that it has complied fully with the
Medicare requirements, the carrier may reinstate the supplier's billing
number. The carrier may pay for services furnished on or after the
effective date of the reinstatement. A carrier's refusal to reinstate a
billing number is not an initial determination under Sec. 405.803.
(g) Reopening of carrier determination, carrier hearing officer
decision, or HCFA decision. An initial carrier determination, a
decision of a carrier hearing officer, or a decision of a HCFA official
may be reopened by the carrier, hearing officer, or HCFA official in
accordance with Secs. 405.841 and 405.842.
(h) Effective date for DMEPOS supplier billing number. If a
carrier, carrier hearing officer, or HCFA official determines that a
DMEPOS supplier's disallowed enrollment application meets the standards
in Sec. 424.57 of this chapter, the determination establishes the
effective date of the billing number as not earlier than the date the
carrier made the determination to disallow the supplier's enrollment
application. Claims are rejected for services furnished before that
effective date.
(i) Submission of claims. A supplier succeeding in having its
enrollment application disallowance or billing number revocation
reversed, or in having its billing number reinstated, may submit claims
to the carrier for services furnished during periods of Medicare
qualification, subject to the limitations in Sec. 424.44 of this
chapter regarding the timely filing of claims. If the claims previously
were filed timely but were rejected, they will be considered filed
timely upon resubmission.
[[Page 57436]]
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance Program; and No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: July 7, 1999.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
Dated: July 13, 1999.
Donna E. Shalala,
Secretary.
[FR Doc. 99-27623 Filed 10-22-99; 8:45 am]
BILLING CODE 4120-01-P