On December 21, 2000, as part of BIPA, Congress enacted sweeping changes in certain Medicare appeals processes by revising certain appeal mechanisms established under section 1869 of the Social Security Act.

BIPA section 521 establishes many changes to the structure and process for appealing the denial of Part A and Part B claims. CMS published proposed rules to implement these changes on November 15, 2002. 67 Fed. Reg. 69,312. Some of the more notable changes to claims appeals procedures under BIPA section 521 and the newly proposed rules are:

A uniform process for handling all Medicare Part A and Part B claims appeals;
Revised time limits for filing appeals;
Revised uniform amount in controversy (AIC) threshold of $100 at the Administrative Law Judge (ALJ) level;
Reduced decision-making time frames throughout all levels of the process, with rights to escalate an appeal to the next level if the decision is not timely;
Review by new entities, known as qualified independent contractors (QICs), which are independent of the intermediary or carrier that made the initial determination or redetermination;
Right to an expedited determination when an individual disagrees with a provider's decision to discharge the individual or terminate services; and
Reopening provisions in the proposed rules which strongly favor reopenings against providers and extend the time limits for reopenings beyond what is reasonable in expecting finality to these determinations.

Click here to view a chart, reproduced from CMS's November 15, 2002 proposed rule, that compares the old and newly proposed claims appeal mechanisms.

Although BIPA requires that all of its section 521 provisions are to be applicable to initial determinations made on or after October 1, 2002, CMS asserted in an October 7, 2002 Federal Register notice that it intends to implement only three of the section 521 changes timely: (1) 120-day deadline for filing requests for redeterminations of initial determinations; (2) reduced $100 AIC threshold for requesting an ALJ hearing; and (3) contractor's review before appeal and no redetermination by individual involved in the initial determination.

BIPA section 522 creates a new process for challenges to national coverage determinations (NCDs) and local coverage determinations (LCDs). The appeals process is separate and apart from the individual claims appeals process established by section 521. CMS published proposed rules to implement these changes on August 22, 2002. 67 Fed. Reg. 54,534. Some of the more notable changes to the NCD and LCD appeals process under BIPA section 522 and the newly proposed rules are:

Only beneficiaries who are "in need" of a particular item or service may appeal an NCD or LCD.
The appeal must be taken before the item or service in need has been provided. If the item or service has been provided, appeal must be taken pursuant to section 521.
Appeals of NCDs are conducted by the HHS Departmental Appeals Board (Board).
Appeals of LCDs are conducted by an ALJ of the Social Security Administration.
Decisions of the Board and ALJs are subject to judicial review.

BIPA requires implementation of section 522 by October 1, 2001. However, CMS, in a September 28, 2001 ruling, directed Medicare contractors not to act on complaints challenging LCD/NCDs until CMS publishes final rules. Ruling No. 01-01.

For a more detailed discussion of the revised Medicare appeals processes, please refer to Ms. Goldsmith's article, "CMS's Newly Proposed Appeals Procedures."