Appealing an Initial Determination

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. 

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 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.

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 reconsideration appeals:

• 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.

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

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.

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.

The Appeals 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.

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.

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

No.

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.

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.

Second Level Informal Hearing Appeals are filed using the CMS Office of Hearings Case and Document Management System (OH CDMS). The OH CDMS is a web-based portal for RDS Plan Sponsors to submit and manage their Second Level Informal Hearing Appeals and to correspond with the CMS Hearing Officer.

The RDS Secure Website (SWS) and the OH CDMS portal are separate web applications requiring separate and unique registrations and account management. CMS’ RDS Center does not maintain the Office of Hearings Case and Document Management System. For more information, refer to Appeal an Initial Determination.

Because the OH CDMS portal falls entirely outside of the RDS Program’s purview, CMS’ RDS Center does not provide technical support for this web application. It is the Plan Sponsor’s responsibility to contact the OH CDMS Help Desk if they are experiencing any issues accessing or using the OH CDMS portal, especially during critical timeframes related to their Appeal(s). Please refer to CMS’ Hearing Officer Electronic Filing page for support and contact information for the OH CDMS portal. User manuals are included on this page to assist with the registration process and the functionality of the Hearing Officer module. For more information, refer to Appeal an Initial Determination.

For purposes of the RDS Program, inaccurate data includes situations where the Plan Sponsor over-reported or under-reported the gross costs associated with one or more specific claims for which some amount of subsidy was requested (i.e., the Plan Sponsor reported gross costs of $30 for a given claim when gross costs for that claim were $20), over-reported or under-reported the Threshold Reduction or Limit Reduction amounts for at least one month for any Benefit Option, or over-reported or under-reported rebates and other price concessions by any amount for at least one month for any Benefit Option. It also includes situations where the Plan Sponsor agreed to a Covered Retiree List that included subsidy periods for specific individuals when in fact one or more of those individuals was not a Qualifying Covered Retiree (as defined in 42 C.F.R. §423.882) for all or part of the CMS-approved subsidy period.

In contrast, for purposes of the RDS Program, incomplete data includes situations where the Plan Sponsor failed to report any of the gross costs associated with one or more specific paid claims. It also includes situations where the Plan Sponsor agreed to a Covered Retiree List that did not include certain individuals who are Qualifying Covered Retirees for all or part of the RDS plan year, and situations where the Plan Sponsor agreed to a Covered Retiree List that included certain individuals, but not for the entire period(s) of time for which those individuals were Qualifying Covered Retirees.

When a Plan Sponsor discovers that it agreed to inaccurate (as opposed to incomplete) retiree data and/or reported inaccurate cost data (see "For purposes of the RDS Program, what is "inaccurate" data, as opposed to "incomplete" data?" for examples of what constitutes inaccurate data) after submitting a Reconciliation payment request or final payment request using the RDS Secure Website Reconciliation process, it must immediately determine whether the inaccurate data had any of the following net effects:

• the Plan Sponsor was paid too much or too little in subsidy for the application
• the Plan Sponsor will be paid too much or too little in subsidy for the application after CMS processes the Reconciliation or final payment request

If either scenario is true, the Plan Sponsor must disclose to CMS the correct gross costs, cost threshold reduction, cost limit reduction, and price concession amount in the aggregate, for the application (i.e., this inaccurate or incomplete final payment data need not be broken down by Benefit Option, by month, for purposes of this disclosure to CMS).

The Plan Sponsor must disclose this information to CMS by submitting an Appeal via the RDS Secure Website in the form of a request for Reconsideration of Reconciliation Final Payment or a request for Reopening of Reconciliation Final Payment. The Plan Sponsor should immediately quantify the difference in subsidy caused by the corrected data and report that dollar amount to CMS as part of the Appeal (regardless of the amount).

When a Plan Sponsor, after submitting its Reconciliation payment request, or its final payment request using the RDS Secure Website Reconciliation process, discovers that it agreed to incomplete (as opposed to inaccurate) retiree data and/or reported incomplete cost data (see "For purposes of the RDS Program, what is "inaccurate" data, as opposed to "incomplete" data?" for examples of what constitutes incomplete data), and has reason to believe that the incomplete data had the net effect of causing the Plan Sponsor to be paid (or that it will be paid) too little in subsidy for the application, it is not required to quantify that difference in subsidy. It is permissible to not disclose the corrected data or the subsidy discrepancy to CMS.

The Plan Sponsor, however, may choose to quantify the difference, and attempt to acquire the difference in subsidy by requesting a reopening. See "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?" for information regarding how to request such a reopening.

After requesting a reopening, CMS will notify the Plan Sponsor whether it may acquire the difference in subsidy, and if so, what further steps the Plan Sponsor must take in order to do so.