42 CFR § 422.311 - RADV audit dispute and appeal processes.
(b) RADV audit results.
(i) Detailed enrollee-level information relating to confirmed enrollee HCC discrepancies.
(ii) The contract-level RADV payment error estimate in dollars.
(iii) The contract-level payment adjustment amount to be made in dollars.
(iv) An approximate timeframe for the payment adjustment.
(2) Compliance date. The compliance date for meeting RADV medical record submission requirements for the validation of risk adjustment data is the due date when MA organizations selected for RADV audit must submit medical records to the Secretary.
(c) RADV audit appeals -
(2) Issues eligible for RADV appeals -
(i) General rules. MA organizations may appeal RADV medical record review determinations and the Secretary's RADV payment error calculation. In order to be eligible for RADV appeal, MA organizations must adhere to the following:
(A) Established RADV audit procedures and requirements.
(B) RADV appeals procedures and requirements.
(ii) Failure to follow RADV rules. Failure to follow the Secretary's RADV audit procedures and requirements and the Secretary's RADV appeals procedures and requirements will render the MA organization's request for appeal invalid.
(iii) RADV appeal rules. The MA organization's written request for medical record review determination appeal must specify the following:
(A) The audited HCC(s) that the Secretary identified as being in error.
(B) A justification in support of the audited HCC selected for appeal.
(iv) Number of medical records eligible for appeal. For each audited HCC, MA organizations may appeal one medical record that has undergone RADV review. If an attestation was submitted to cure a signature or credential-related error, the attestation may be included in the HCC appeal.
(v) Selection of medical record for appeal. The MA organization must select the medical record that undergoes appeal.
(vi) Written request for RADV payment error calculation appeal. The written request for RADV payment error calculation appeal must clearly specify the following:
(3) Issues ineligible for RADV appeals.
(i) MA organizations' request for appeal may not include HCCs, medical records or other documents beyond the audited HCC, RADV-reviewed medical record, and any accompanying attestation that the MA organization chooses for appeal.
(4) Burden of proof. The MA organization bears the burden of proof by a preponderance of the evidence in demonstrating that the Secretary's medical record review determination(s) or payment error calculation was incorrect.
(5) Manner and timing of a request for RADV appeal.
(A) That they may appeal RADV HCC errors that are eligible for medical record review determination appeal.
(C) Whether the MA organization requests both medical record review determination appeal and RADV payment error calculation appeal, the issues with which the MA organization disagrees, and the reasons for the disagreements.
(B) An MA organization's request for appeal of its RADV payment error calculation will not be adjudicated until appeals of RADV medical record review determinations filed by the MA organization have been completed and the decisions are final for that stage of appeal.
(6) Reconsideration stage -
(i) Written request for medical record review reconsideration. A MA organization's written request for medical record review determination reconsideration must specify the following:
(B) A justification in support of the audited HCC chosen for appeal.
(iii) Conduct of the reconsideration.
(A) For medical record review determination reconsideration, a medical record review professional who was not involved in the initial medical record review determination of the disputed audited HCCs does the following:
(1) Reviews the medical record and accompanying dispute justification.
(2) Reconsiders the initial audited medical record review determination.
(iv) Effect of the reconsideration official's decision.
(A) The reconsideration official issues a written reconsideration decision to the MA organization.
(B) The reconsideration official's decision is final unless the MA organization disagrees with the reconsideration official's decision.
(7) Hearing stage -
(i) Errors eligible for hearing. At the time the reconsideration official issues his or her reconsideration determination to the MA organization, the reconsideration official notifies the MA organization of any RADV HCC errors or payment error-calculations that are eligible for RADV hearing.
(iii) Written request for hearing. The written request for a hearing must be filed with the Hearing Officer within 60 days of the date the MA organization receives the reconsideration officer's written reconsideration decision.
(1) Include a copy of the written decision of the reconsideration official;
(2) Specify the audited HCCs that the reconsideration official confirmed as being in error; and
(3) Specify a justification why the MA organization disputes the reconsideration official's determination.
(1) A copy of the written decision of the reconsideration official.
(v) Disqualification of the hearing officer.
(E) If the hearing officer does not withdraw, the objecting party may, after the hearing, present objections and request that the officer's decision be revised or a new hearing be held before another hearing officer. The objections must be submitted in writing to the Secretary.
(vi) Hearing Officer review. The hearing officer reviews the following:
(A) For a medical record review determination appeal, the hearing officer reviews all of the following:
(1) The RADV-reviewed medical record and any accompanying attestation that the MA organization selected for review.
(2) The reconsideration official's written determination.
(1) The reconsideration official's written determination.
(2) Briefs addressing the reconsideration decision.
(vii) Hearing procedures -
(A) Authority of the Hearing Officer. The hearing officer has full power to make rules and establish procedures, consistent with the law, regulations, and the Secretary rulings. These powers include the authority to dismiss the appeal with prejudice and take any other action which the hearing officer considers appropriate, including for failure to comply with such rules and procedures.
(B) The hearing is on the record.
(1) Except as specified in paragraph (c)(viii)(B)(2) of this section, the hearing officer is limited to the review of the record.
(3) The record is comprised of the following:
(i) Written decisions described at paragraphs (c)(6)(iv) and (7)(vi) of this section.
(ii) Written briefs from the MA organization explaining why they believe the reconsideration official's determination was incorrect.
(4) The hearing officer neither receives testimony nor accepts any new evidence that is not part of the record.
(viii) Hearing Officer decision. The hearing officer decides whether to uphold or overturn the reconsideration official's decision, and sends a written determination to CMS and the MA organization, explaining the basis for the decision.
(ix) Computations based on hearing decision.
(A) Once the hearing officer's decision is considered final in accordance with paragraph (c)(7)(x) of this section, a third party not involved in the initial RADV payment error calculation recalculates the MA organization's RADV payment error and issues a new RADV audit report to the appellant MA organization and CMS.
(B) For MA organizations appealing the RADV error calculation only, a third party not involved in the initial RADV payment error calculation recalculates the MA organization's RADV payment error and issues a new RADV audit report to the appellant MA organization and CMS.
(8) CMS Administrator review stage.
(A) The CMS Administrator acknowledges the decision to review the hearing decision in writing and notifies CMS and the MA organization of their right to submit comments within 15 days of the date of the notification; and
(1) The record is comprised of documents described at paragraph (c)(7)(vii)(B)(3) of this section.
(2) The hearing record.
(A) Declines to review the hearing officer's decision; or
(B) Does not make a decision within 60 days.
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