Validation of Integrated Administrative Hearing Officer Decisions. As part of the Administration and Oversight activities set forth in this MOU and for purposes of validating that Integrated Administrative Hearing Officer decisions are supported by applicable Medicare law, regulations and coverage criteria, all decisions related to Medicare coverage will also be reviewed by the Part C qualified independent contractor (QIC) for a period of at least one (1) and not to exceed two (2) years. The FIDA-IDD Plan will be responsible for automatically forwarding a complete paper copy of the administrative case file to the Part C QIC. OTDA will be responsible for forwarding a complete paper copy of its decision to designated CMS staff, who will compare the OTDA decision with the QIC decision. The primary purpose of this process is for quality assurance and to provide feedback to OTDA to ensure that cases are adjudicated according to Medicare rules. The Part C QIC’s review does not suspend or toll the enrollee’s right to request review from the Medicare Appeals Council. CMS reserves the right to make any necessary adjustments to the appeals process to assure beneficiary access to Medicare items and services. CMS and NYSDOH will evaluate whether and how to continue this quality assurance process in subsequent demonstration years.
Validation of Integrated Administrative Hearing Officer Decisions. As part of the Administration and Oversight activities set forth in this MOU and for purposes of validating that Integrated Administrative Hearing Officer decisions are supported by applicable Medicare law, regulations and coverage criteria, all decisions related to Medicare coverage will be reviewed by the Part C qualified independent contractor (QIC) for a period not to exceed one (1) year. OTDA will be responsible for forwarding a complete paper copy of the administrative case file to the Part C QIC within two (2) days of the Integrated Administrative Hearing Officer’s decision. The primary purpose of the Part C QIC’s review is for quality assurance and to provide feedback to OTDA to ensure that cases are adjudicated according to Medicare rules. The Part C QIC’s review does not suspend or toll the enrollee’s right to request review from the Medicare Appeals Council. CMS reserves the right to make any necessary adjustments to the appeals process to assure beneficiary access to Medicare items and services.
Validation of Integrated Administrative Hearing Officer Decisions. CMS and NYSDOH are establishing a quality oversight process for the integrated appeal system. As part of this quality review process, the FIDA plan shall forward all or a portion of adverse appeal decisions for quality oversight, as will be specified in forthcoming guidance. This quality oversight process will not alter the integrated appeals process set forth in this Section of this contract.
