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<REGINFO_RIN_DATA xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" RUN_DATE="2026-10-23-04:00" xsi:noNamespaceSchemaLocation="https://www.reginfo.gov/public/xml/REGINFO_XML_Ver10262011.xsd">
    <RIN_INFO>
        <RIN>0938-AM73</RIN>
        <PUBLICATION>
            <PUBLICATION_ID>200310</PUBLICATION_ID>
            <PUBLICATION_TITLE>The Regulatory Plan and the Unified Agenda of Federal Regulatory and Deregulatory Actions</PUBLICATION_TITLE>
        </PUBLICATION>
        <AGENCY>
            <CODE>0938</CODE>
            <NAME>Centers for Medicare &amp; Medicaid Services</NAME>
            <ACRONYM>CMS</ACRONYM>
        </AGENCY>
        <PARENT_AGENCY>
            <CODE>0900</CODE>
            <NAME>Department of Health and Human Services</NAME>
            <ACRONYM>HHS</ACRONYM>
        </PARENT_AGENCY>
        <RULE_TITLE>Revisions to the Appeals Process for Initial Claim Determinations (CMS-4064-F)</RULE_TITLE>
        <ABSTRACT><![CDATA[This final rule will revise the Medicare appeals process by adding five-tiered (five levels) of review.  It will remove the distinction between the processing of initial determination and appeals under part A and part B required by section 521 of Benefits Improvement and Protection Act of 2000 (BIPA).]]></ABSTRACT>
        <PRIORITY_CATEGORY>Economically Significant</PRIORITY_CATEGORY>
        <RIN_STATUS>First Time Published in The Unified Agenda</RIN_STATUS>
        <RULE_STAGE>Final Rule Stage</RULE_STAGE>
        <MAJOR>Undetermined</MAJOR>
        <UNFUNDED_MANDATE_LIST>
            <UNFUNDED_MANDATE>Undetermined</UNFUNDED_MANDATE>
        </UNFUNDED_MANDATE_LIST>
        <CFR_LIST>
            <CFR>42 CFR 40S</CFR>
        </CFR_LIST>
        <LEGAL_AUTHORITY_LIST>
            <LEGAL_AUTHORITY>Sec 521 of BIPA</LEGAL_AUTHORITY>
        </LEGAL_AUTHORITY_LIST>
        <LEGAL_DLINE_LIST/>
        <RPLAN_ENTRY>Yes</RPLAN_ENTRY>
        <RPLAN_INFO>
            <STMT_OF_NEED><![CDATA[This regulation is necessary to implement section 1869 of the Social Security Act (the Act). Major provisions include the following:

1. The implementation of identical rules for Medicare part A and B claims appeals.
2. The establishment of qualified independent contractors (QICs), with panels of physicians making medical necessity determinations.
3. Shorter time frames at all appeal levels.
4. Other improvements to the Medicare claims appeals process. 

Key components of the final rule include new notice and evidence submission standards, the procedures for adjudicating escalated cases, the promulgation of Medicare-specific regulations for administrative law judge hearings,  the feasibility of telephone and in-person appeals under the new BIPA timeframes, reopening rules, and transition policies for the move from the existing appeals procedures.]]></STMT_OF_NEED>
            <LEGAL_BASIS><![CDATA[Section 1869(b) of the Act, as amended by section 521 of Benefits Improvement & Protection Act of 2000, requires the Secretary to implement claims appeal procedures by October 1, 2002.]]></LEGAL_BASIS>
            <ALTERNATIVES><![CDATA[None, the changes are required by the statute.]]></ALTERNATIVES>
            <COSTS_AND_BENEFITS><![CDATA[None, the changes are required by the statute.]]></COSTS_AND_BENEFITS>
            <RISKS><![CDATA[None, the changes are required by the statute.]]></RISKS>
        </RPLAN_INFO>
        <TIMETABLE_LIST>
            <TIMETABLE>
                <TTBL_ACTION>Final Action</TTBL_ACTION>
                <TTBL_DATE>07/00/2004</TTBL_DATE>
            </TIMETABLE>
        </TIMETABLE_LIST>
        <RFA_REQUIRED>No</RFA_REQUIRED>
        <GOVT_LEVEL_LIST>
            <GOVT_LEVEL>Federal</GOVT_LEVEL>
        </GOVT_LEVEL_LIST>
        <FEDERALISM>No</FEDERALISM>
        <ENERGY_AFFECTED>No</ENERGY_AFFECTED>
        <PRINT_PAPER>NA</PRINT_PAPER>
        <INTERNATIONAL_INTEREST>Not Collected</INTERNATIONAL_INTEREST>
        <RELATED_RIN_LIST>
            <RELATED_RIN>
                <RIN>0938-AK69</RIN>
                <RIN_RELATION>Related to</RIN_RELATION>
            </RELATED_RIN>
        </RELATED_RIN_LIST>
        <AGENCY_CONTACT_LIST>
            <CONTACT>
                <FIRST_NAME>Janet </FIRST_NAME>
                <LAST_NAME>Miller</LAST_NAME>
                <TITLE>Health Insurance Specialist</TITLE>
                <AGENCY>
                    <CODE>0938</CODE>
                    <NAME>Centers for Medicare &amp; Medicaid Services</NAME>
                    <ACRONYM>CMS</ACRONYM>
                </AGENCY>
                <PHONE>410 786-1588</PHONE>
                <MAILING_ADDRESS>
                    <STREET_ADDRESS>N2-14-26, S1-06-04, 7500 Security Boulevard,</STREET_ADDRESS>
                    <CITY>Baltimore</CITY>
                    <STATE>MD</STATE>
                    <ZIP>21244</ZIP>
                </MAILING_ADDRESS>
            </CONTACT>
        </AGENCY_CONTACT_LIST>
    </RIN_INFO>
</REGINFO_RIN_DATA>
