There seems to be great confusion as to MEDICARE or Carrier appeals. When a review decision arrives the provider or patient has 6 months to request a fair hearing. When the hearing officer's decision is made, the patient or provider has 60 days to request an Administrative Law Judge hearing. Most reimbursement people know that all they need do to take the appeal is to simply state: "we hereby request a fair hearing", or "we hereby request a hearing by a hearing officer, or "we hereby request a hearing by an Administrative Law Judge". Send such a request within the 6 months period, or within the 60 day period, whichever is applicable, and the hearing will normally be granted. Of course, you should also say where the hearing should be held, if in person, or you should request a "telephone hearing", and in most cases they will be granted, in the place pursuant to your request. ALJ hearings are held in the most convenient place for the provider or the patient. We have been informed that the Office of Hearings and Appeals has now decided that all ALJ hearings should be held in the area where the treatment occurred, but we have been unable to confirm that, as yet.

For the purposes of this article we are confining our discussion to the problems of time. We have learned from one that when the local branches mess up, and forget to file timely the request for a hearing, the file is closed and written off. DO NOT DO THAT. IF THE TIME TO FILE HAS PASSED IT IS STILL POSSIBLE TO FILE LATE, ESPECIALLY IF THE DENIAL IS CLEARLY WRONG.

The regulations state that the appellant may, within 1 year, request that the file be re-opened. And good cause need not be shown, although it is better to show good cause. We have had files reopened even though the office of hearing and appeals said that it cannot be opened after 6 months. We simply cited 42 CFR 405.841, which states that a decision may be reopened within 12 months after it is made, without showing good cause. After 1 year and less than 4 years it may not be opened except ~r good cause. Many reimbursement people are not aware of the possibility of reopening a case when the time has passed. After reading this Newsletter there is no excuse. If the time has passed, request that the case be reopened, or send it to a qualified person so the case can be reopened. It is true that the hearings and appeals office may not allow it to be opened, but they frequently are wrong, and the case should be reopened. If they refuse, come back with a good cause, and in additions show that the decision sought to be appealed was clearly vvrong. We have done it . If a mistake was made in allowing the time to elapse, don't make another one by failing to request the reopening.