HI 00208.035 Role of the Division of Reimbursement, Recovery and Reconsideration Evaluation, Bureau of Program Operations

The Division of Reimbursement, Recovery, and Reconsideration Evaluation is primarily responsible for directing the processing of CMS appeals and overpayments, and planning, directing and coordinating the monitoring of Medicare and Medicaid Program guidelines designed to review and evaluate CMS reimbursement and accounting policy. Some of the Division’s specific functions are as follows:

1. A. 

   The adjudication of requests for reconsideration of Part A claim denials initially processed by intermediaries, which are unable to conduct their own reconsiderations.

2. B. 

   The evaluation of intermediaries’ performance in processing Part A appeals and the preparation of reports from which intermediaries are rated for Contractor Performance Evaluation Program purposes.

3. C. 

   The review of all Medicare, Medicaid, and PSRO decisions on which a hearing before the Office of Disability Adjudication and Review (ODAR) has been requested.

4. D. 

   The final review of all Part A Medicare and Medicaid decisions by ODAR on health insurance appeals.

5. E. 

   The evaluation and review of Medicare beneficiary, provider, and physician /supplier overpayment cases, and the determination and adjudication of recovery actions.