Appealing an Initial Determination

User Roles:

AM

AR

D

Program Components:

Annual Plan Application

Reconciliation

This page contains answers to Common Questions about appealing an initial determination. Review this page to learn about how to request an appeal, how to withdraw an appeal, and more. For additional information refer to the Appeal an Initial Determination section of the RDS User Guide.

What is an appeal?

ANSWER: RDS Plan Sponsors have the right to appeal various types of RDS Program determinations in accordance with Federal regulations at 42 C.F.R. §423.890. An appeal can take the form of either a reconsideration or a reopening request. For information about appeals, refer to Introduction to Appeals.

Answer ID: 4000-1
Date Posted: 10/17/2014

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What is an initial determination?

ANSWER: An initial determination is a decision made by CMS' RDS Center in response to information that the Plan Sponsor submitted. If a Plan Sponsor disagrees with the initial determination made by CMS' RDS Center, it can submit a reconsideration request.

Answer ID: 4000-2
Date Posted: 10/17/2014

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What are appealable initial determinations?

ANSWER: The two appealable initial determinations are as follows:

  • Did not meet the Application Deadline: For detailed information about the Application Deadline, including what is required to be submitted by the Application Deadline, refer to Important Application Deadline Information.
  • Reconciliation Final Payment: The Plan Sponsor does not agree with the Reconciliation or final payment determination.

 

Answer ID: 4000-3
Date Posted: 10/17/2014

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What is a reconsideration request?

ANSWER: An initial determination is a decision made by CMS' RDS Center in response to information that the Plan Sponsor submitted. If a Plan Sponsor disagrees with the initial determination made by CMS' RDS Center, it can submit a reconsideration request. The following are the two types of initial determinations for which a Plan Sponsor may submit a reconsideration request using the RDS Secure Website: Did not meet the Application Deadline and Reconciliation Final Payment.

There are 3 levels of reconsiderations:

  • First level: Reconsideration
  • Second level: Informal Hearing
  • Third level: Administrator Review

The second and third levels of reconsideration-related appeals are not requested using the RDS Secure Website. Plan Sponsors receive instructions regarding how to request additional level of appeals once a first level appeal decision is made by CMS' RDS Center.

Answer ID: 4000-4
Date Posted: 10/17/2014

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Who may request an appeal?

ANSWER: The Account Manager, Authorized Representative, and Designee with Submit Appeal privilege may request an appeal.

Answer ID: 4000-5
Date Posted: 10/17/2014

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How do I request an appeal?

ANSWER: For information about the three levels of reconsideration-related appeals, as well as step-by-step instructions to request an appeal, refer to Appeal an Initial Determination.

Answer ID: 4000-6
Date Posted: 10/17/2014

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What is a Hearing Officer?

ANSWER: A CMS Hearing Officer is an individual designated by the Centers for Medicare and Medicaid Services (CMS) to conduct the appeals process for a reconsideration or reopening request. Within 30 calendar days from receipt of the request for the hearing, a CMS Hearing Officer schedules a hearing to review the request.

Answer ID: 4000-7
Date Posted: 10/17/2014

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How do I view the status of my appeal?

ANSWER: The Appeal Summary section of the Manage Appeals page in the RDS Secure Website indicates the status of the appeal. The status and other details about the appeal are also available on the View Appeal page. Refer to View an Appeal for step-by-step instructions.

Answer ID: 4000-9
Date Posted: 10/17/2014Last Updated: 12/19/2015

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What are the different appeal statuses?

ANSWER: The appeal statuses include: Reconsideration Requested, Reopening Requested, Appeal Under Review, Approved, Denied, Invalid, Pending, and Withdrawn. Refer to Appeal Statuses for a description of each status.

Answer ID: 4000-10
Date Posted: 10/17/2014Last Updated: 03/12/2015

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How do I withdraw an appeal?

ANSWER: The Plan Sponsor may withdraw an appeal through the RDS Secure Website. Refer to Withdraw an Appeal for step-by-step instructions.

Answer ID: 4000-11
Date Posted: 10/17/2014

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Do any actions taken or not taken by an RDS Plan Sponsor affect the CMS' right to reopen and revise an initial or reconsidered determination upon its own motion as specified in regulations at 42 C.F.R.§423.890?

ANSWER: No.

Answer ID: 4000-12
Date Posted: 10/17/2014

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How would an RDS Plan Sponsor request a reopening of a Reconciliation or final payment determination, when it believes the determination is incorrect due to inaccurate or incomplete cost data?

ANSWER: Refer to Appeal a Reconciliation Final Payment Determination in the RDS User Guide for details about what information to include in a request for reopening, as well as how to submit the request in the RDS Secure Website.

Answer ID: 4000-13
Date Posted: 10/17/2014Last Updated: 12/19/2015

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What is a reconsideration versus a reopening?

ANSWER: An appeal is classified as either a reconsideration or a reopening based on the timeframe in which the appeal is submitted. A Plan Sponsor may request a reconsideration on an application denial or a Reconciliation final payment determination. For more information about appeal types, including timeframes for submitting an appeal, refer to Reconsideration versus Reopening.

Answer ID: 4000-14
Date Posted: 03/12/2015

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