CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 92 0000. ref SDS 91 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 010427 0830 meeting at Kaiser - Doctor Johnson notes Millie looks
040902 - so good nobody can believe she has such severe cancer, ref SDS 45
040903 - OJ6I; the doctor explained again Millie's cancer has mutated through
040904 - 11 relapses to resist chemotherapy.  The doctor advised that Kaiser
040905 - has a new strategy prescribing therapy that is effective for treating
040906 - cancer as a chronic disease by "targeting" the genetic profile of
040907 - cancer that has mutated in patients, like Millie, to resist
040908 - chemotherapy. ref SDS 45 SJ6N
040910 -  ..
040911 - On 100501 1037 Millie letter to medical team confirms understanding of
040912 - new strategy to treat Millie's cancer with targeted therapy.
040913 - ref SDS 46 F25O
040915 -  ..
040916 - On 100501 2017 Doctor Rugo reports plans to collaborate with Doctor
040917 - Johnson at Kaiser on work plan for Millie to recover from 11th relapse
040918 - of cancer caused by UCSF medical mistakes. ref SDS 47 HH4I
040920 -  ..
040921 - On 100502 2143 Kaiser confirms that some patients respond well to new
040922 - "targeted" therapies. ref SDS 48 YX8L  Kaiser contends that all of the
040923 - strategies for "targeted" therapies have been executed for Millie,
040924 - which seems conflicting with the record in this case. ref SDS 48 MZ4N
040926 -  ..
040927 - On 100503 1522 Millie notifies medical team that time of the essence
040928 - to get the next treatment going. ref SDS 49 TD5W
040930 -  ..
040931 - On 100503 1945 Kaiser notifies Millie to get remaining 2 treatments
040932 - with Abraxane chemotherapy that seems to be failing, and then after 3
040933 - more weeks without treatment, following a trip abroad, the doctor will
040934 - discuss "next steps." ref SDS 50 YL5N
040936 -  ..
040937 - On 100503 2338 Millie reports to medical team that she will implement
040938 - Kaiser's guidance to delay changing treatments, and takes Kaiser's
040939 - letter on 010503, as assurance that recovery will be equal to changing
040940 - treatment immediately on 100505. ref SDS 51 6X7S
040942 -  ..
040943 - On 100504 1609 Sara, Practice Manager for the UCSF Oncology Breast
040944 - Care Clinic, called and notified Millie that Doctor Rugo will soon
040945 - communicate with Doctor Johnson, or had already done so, to coordinate
040946 - with Kaiser on planning Millie's next treatment to recover from the
040947 - 11th relapse of cancer. ref SDS 52 NT5N
040949 -  ..
040950 - On 010505 0730 Millie received the 2nd treatment at Kaiser for the 3rd
040951 - cycle of Abraxane chemotherapy, as ordered by Doctor Johnson.
040952 - ref SDS 53 KE4K
040954 -  ..
040955 - On 100511 0900 cancer marker CA 15-3 520 increased another 100 points,
040956 - seemingly on an accelerating rise, which threatens to cascade out of
040957 - control, because Abraxane chemotherapy is not effective. ref SDS 54
040958 - L54I
040960 -  ..
040961 - On 100512 0730 Millie received 3rd treatment for 3rd cycle of
040962 - Abraxane. ref SDS 55 KE4K
040964 -  ..
040965 - On 100515 1415 Millie departed 2-week trip to Europe. ref SDS 56 PK9O
040967 -  ..
040968 - On 100527 0217 Millie files claim with Kaiser Claims Resolution
040969 - Department for standard of care to recover from 11th relapse of cancer
040970 - caused by medical mistakes getting radiation treatments at UCSF on
040971 - referral from Kaiser. ref SDS 57 IZ7N
040973 -  ..
040974 - On 100528 0322 Millie requests support from Medicare to separate
040975 - recovery for medical mistakes getting radiation from UCSF, from health
040976 - care benefits limited by Medicare insurance coverage. ref SDS 58 QQ6N
040978 -  ..
040979 - On 100528 1031 called Medicare they have formed a team to review
040980 - Millie's case, and contacted Kaiser's Claims Resolution Department for
040981 - response to Millie's claim. ref SDS 59 4W5F
040983 -  ..
040984 - 100601 0830 Doctor Johnson reported that Kaiser has not had time to
040985 - collaborate with UCSF on treatment for Millie to recover from UCSF
040986 - medical mistakes.  He discussed treating Millie with MPA, but this was
040987 - not prescribed because Millie was treated with MPA in 2009, and UCSF
040988 - ended the treatment due to fears about blood clot side effects, which
040989 - were believed to cause breathing problems Millie had, though later
040990 - breathing problems were discovered to be caused by defective radiation
040991 - treatment.  Since Doctor Johnson said Kaiser has no more treatments
040992 - for Millie, the only way Millie can get relief from pain caused by
040993 - cancer that is progressing without treatment is get treatment in
040994 - Hospice.  Since Hospice is the only choice of care offered today,
040995 - Millie accepted this.
040997 -  ..
040998 - On 100601 1531 Sharon called to schedule starting Hospice medical
040999 - services beginning tomorrow between 0900 - 1000. ref SDS 46 036C
041001 -  ..
041002 - On 100602 0913 Liz provides orientation on Hospice care; she confirms
041003 - Sharon's report yesterday, that if Kaiser performs on the insurance
041004 - agreement to provide standard of care for Millie's patient profile,
041005 - than Millie can elect to recover from 11th relapse of cancer, rather
041006 - than continue with Hospice support for dying peacefully. ref SDS 47
041007 - 036C
041009 -  ..
041010 - On 100602 1046 Diane received notice from Medicare to file claim for
041011 - Millie to get treatment for recovering from UCSF medical mistakes; she
041012 - is preparing a statement of claim. ref SDS 64 036C  Advised Diane to
041013 - use Millie's statement of claim submitted to Kaiser on 100527.
041014 - ref SDS 64 MZ5H  Eileen called later and reported that Kaiser denied
041015 - Millie's claim on the grounds that Medicare does not authorize payment
041016 - for treatment to recover from cancer, after a patient starts Hospice.
041017 - ref SDS 64 UN4M  Requested that Eileen read he claim and then make a
041018 - good faith determiantion. ref SDS 64 I33H  Eileen called back after
041019 - reading the claim and advised the denial of claim has been withdrawn,
041020 - and the matter is referred to Claims Resolution Department.
041021 - ref SDS 64 UN5P
041023 -  ..
041024 - On 100603 0449 Millie notified medical team that Kaiser called today
041025 - about moving forward to resolve medical mistakes getting radiation
041026 - treatment at UCSF on referral from Kaiser. ref SDS 65 IX9Q
041028 -  ..
041029 - On 100606 1604 Doctor Johnson notifies Millie that her cancer marker
041030 - has remained fairly stable the past 3 weeks since ending treatment
041031 - with Abraxane on 100512; actually went up less without Abraxane, than
041032 - with it, because Millie's cancer resists chemotherapy. ref SDS 66 036C
041034 -  ..
041035 - On 100606 1638 Millie thanks Doctor Johnson for submitting good news
041036 - cancer marker CA 15-3 606 much smaller rise than exptected after
041037 - ending treatment for 3 weeks. ref SDS 67 036C; asks if Doctor Rugo ever
041038 - returned Doctor Johnson's call from Kaiser, as planned in Doctor
041039 - Rugo's letter on 100501?
041041 -  ..
041042 - On 100606 2317 Millie receives letter from Doctor Johnson reporting
041043 - that Doctor Rugo has never returned his call asking UCSF for Millie's
041044 - treatment plan, which demonstrates failure to perform on Doctor Rugo's
041045 - commitment in UCSF letter sent to the medical team on 100501.
041046 - ref SDS 68 036C
041048 -  ..
041049 - On 100607 0932 called Cherry at Medicare about progress on contacting
041050 - Kaiser to process Millie's claim filed on 100527, and planned in the
041051 - call with Medicare (Cherry and Beth) as action item #8, planned the
041052 - next day on 100528 1031, ref SDS 59 PE6P; today, Cherry did not have
041053 - time to return the call. ref SDS 69 036C
041055 -  ..
041056 - On 100607 1021 called Paula at Kaiser - she said someone else is
041057 - handling Millie's claim, because the claim has not been denied, and
041058 - Paula only handles denied claims. ref SDS 70 036C; Paula further
041059 - reported that Kaiser no longer objects to demaning UCSF correct
041060 - medical mistakes, so Millie's claim should be easy to resolve.
041061 - ref SDS 70 QN9F
041063 -  ..
041064 - On 100607 1117 letter to Paula confirming Kaiser's work plan to
041065 - process Millie's claim for care promptly in order to save her life.
041066 - ref SDS 71 036C
041068 -  ..
041069 - On 100608 1521 called and talked to Cherry and Beth about expediting
041070 - Millie's claim at Kaiser. ref SDS 72 036C  Developed work plan to have
041071 - a conference call with Kaiser tomorrow. ref SDS 72 C354  Submitted
041072 - letter to Kasier and CMS Medicare confirming work plan for tomorrow.
041073 - ref SDS 72 G84Q
041075 -  ..
041076 - On 100609 1114 called CMS to expedite conference call on expediting
041077 - Millie's care. ref SDS 73 036C  Cherry called and schedule telecon with
041078 - Kaiesr and CMS today 1300. ref SDS 73 8O4H  Received letter from Cherry
041079 - at CMS confirming work plan for conference call at 1300. ref SDS 73
041080 - PRXY
041082 -  ..
041083 - On 100609 1232 letter to CMS and Kaiser submitts agenda for conference
041084 - call to review progress on Kaiser resolving Millie's claim for
041085 - recovery from UCSF medical mistakes. ref SDS 74 036C
041087 -  ..
041088 - On 100609 1300 CMS and Kaiser conference call to report progress on
041089 - reviewing Millie's claim for treatment to recover from UCSF medical
041090 - mistakes in time to be effective. ref SDS 75 036C
041092 -  ..
041093 - On 100609 1522 Jennifer called for assistance processing Millie's
041094 - claim to recover from medical mistakes getting radiation treatment at
041095 - UCSF on referral from Kaiser. ref SDS 76 036C
041097 -  ..
041098 - On 100611 1451 Jennifer advised Kaiser extended the date for
041099 - responding to Millie's claim from 100610 to 100624, based on Millie
041100 - filing updated statement of authorized representative. ref SDS 80 036C
041101 - Jennifer reported she reviewed 6-issues discussed on 100609, and will
041102 - address these issues responding to Millie's claim. ref SDS 80 FQ4G
041103 - Jennifer asked how Kaiser can treat Millie to recover from UCSF
041104 - medical mistakes, if Millie refuses chemotherapy and has entered
041105 - Hospice. ref SDS 80 FQ4M
041107 -  ..
041108 - On 100611 2326 Millie received Jennifer's letter confirming the date
041109 - for Kaiser to respond to Millie's claim has been extended to 100624,
041110 - ref SDS 81 CV4O, and further advising that issues Kaiser will determine
041111 - responding to Millie's claim for recovering from UCSF medical
041112 - mistakes, ref SDS 81 036C, are as set out in the record for telecon on
041113 - 100609. ref SDS 76 XK50  Jennifer will call on 100615, to report
041114 - progress on respnding to Millie's claim. ref SDS 81 6P53
041116 -  ..
041117 - On 100614 0257 letter to Kaiser Medicar CMS claim team requests
041118 - immediate written proposal evaluating treatment options for Millie to
041119 - consider. ref SDS 82 036C
041121 -  ..
041122 - On 100616 0832 called Jennifer about her plan to call yesterday on
041123 - Tuesday to report progress Kaiser responding to Millie's claim, as set
041124 - out in Jennifer's letter on 100611. ref SDS 83 036C   Jennifer called
041125 - back to ask if Millie wants UCSF or Kaiser to pay for her damages
041126 - caused by UCSF medical mistakes. ref SDS 83 PSSV  Jennifer reported
041127 - delays communicating with Millie's medical team have delayed making
041128 - arrangements for Millie to start treatment recovering from UCSF
041129 - medical mistakes. ref SDS 83 OY4T  She plans to call on Friday, 100618,
041130 - to report progress responding to Millie's claim. ref SDS 83 1K5J
041132 -  ..
041133 - On 100618 0843 called Jennifer at Memeber Case Resolution Department
041134 - about progress responding to Millie's claim. ref SDS 84 036C
041136 -  ..
041137 - On 100620 1112 letter to Kaiser claim team with copy to Medicare, and
041138 - the medical team requests call on Monday 100621, planned for previous
041139 - Friday, 100628, to report progress getting Millie treatment.
041140 - ref SDS 85 036C  Recommends that delay communicating with medical team
041141 - that has delayed Millie starting treatment in time to be effective,
041142 - ref SDS 85 L59P, can be solved by hiring MD Anderson. ref SDS 85 L59X
041144 -  ..
041145 - On 100621 0853 called for Jennifer and left several messages,
041146 - including for her team lead. ref SDS 87 036C  Nobody had time today
041147 - for calling back. ref SDS 87 OP3N
041149 -  ..
041150 - On 100622 1027 Jennifer called and advised that Doctor Johnson
041151 - responded to request for comment on Millie's claim saying he cannot
041152 - provide care for Millie because she entered Hospice on 100601,
041153 - ref SDS 89 036C; recommended Jennifer check Kaiser's medical chart for
041154 - Millie meeting with Doctor Johnson to see Millie was given no choices
041155 - except to enter Hospice in order to avoid further pain and suffering.
041156 - ref SDS 89 NX68
041158 -  ..
041159 - On 100622 1511 letter to claim team and Medicare, and to Millie's
041160 - medical team confirming understanding in Jennifer's call that Millie's
041161 - medical team at Kaiser seems to refuse Millie standard of care to
041162 - recover from UCSF medical mistakes, because she was forced to enter
041163 - Hospice to get relief from pain caused by UCSF medical mistakes.
041164 - ref SDS 90 036C  UCSF delays compounded Millie's injuries, pain, and
041165 - suffering; caution must be exercised to enable recovery, based on
041166 - Millie's right to life. ref SDS 90 575U   Millie's patient history
041167 - shows the doctor's only issue, ref SDS 90 576V, is having time to
041168 - providing standard of care for Millie to recover from medical
041169 - mistakes, and if not, then Kaiser should assign someone who does.
041170 - ref SDS 90 583Y  Kaiser has violated Millie's human rights; a woman's
041171 - right to choose life for herself, should be no less than the right to
041172 - choose for her unborn child, since the right to life and due process
041173 - are protected by the US Constitution. ref SDS 90 584W  Kaiser can
041174 - easily solve the time problem by hiring other people to do the work,
041175 - and charging UCSF. ref SDS 90 585P
041177 -  ..
041178 - 100624 1616 Jennifer called and asked to extend Kaiser's response to
041179 - Millie's claim another day or so, for review with her boss, and with
041180 - the customer. ref SDS 91 036C  Jennifer the original date for Kaiser to
041181 - respond on 100610, required by statute, and then amended to today on
041182 - 100624, can be further amended, and cited unclear authority about 30
041183 - days instead of 14. ref SDS 91 EG5P  Agreed that extending Kaiser's
041184 - response another few days until tomorrow, or Monday, is an acceptable
041185 - risk, even though Millie's cancer markier has increased significantly
041186 - to over 1000, and so that an equitable solution can be implented that
041187 - allows treatment in time to be effective for Millie. ref SDS 91 EG73
041188 - Jennifer will submit her draft response, and call tomorrow for
041189 - discussing Kaiser's solution. ref SDS 91 H98M
041191 -  ..
041192 - On 100625 0852 letter to Kaiser and Medicare claim teams confirming
041193 - Kaiser's request to extend date for responding to Millie's claim
041194 - another few days until Monday in order to get comprehensive solution.
041195 - ref SDS 92 036C
041197 -  ..
041198 - On 100626 0917 received letter from Cherry at Medicare, ref SDS 0
041199 - 036C, submitting CMS regulations, that control due date for Kaiser to
041200 - respond to Millie's claim. ref SDS 0 N64I
041201 -
041202 -
041203 -
041205 -  ..
0413 -
0414 -
0415 - Progress
0416 -
041601 - Letter to Kaiser and Medicare (CMS) claim teams, and to the medical
041602 - team says...
041603 -
041604 -    1.  Subject: CMS regs Kaiser Response Millie's Claim 14 Days
041605 -        Date: Fri, 25 Jun 2010 20:08:27 -0400
041614 -         ..
041615 -    2.  Per your request [...in the letter to the claim teams at Kaiser
041616 -        and at Medicare on 100625 0852. ref SDS 92 1X6R...] attached
041617 -        above is our regulation.
041619 -         ..
041620 -    3.  The exact citation for the 14-day timeframe is located at:
041621 -
041622 -        422.570 (d)(1) Expediting certain organization determinations:
041623 -        Actions following denial.  If an MA organization denied a
041624 -        request for expedited determination, it must take the following
041625 -        actions: (1) Automatically transfer a request to the standard
041626 -        timeframe and make the determination within the 14-day
041627 -        timeframe established in 422.568 for a standard determination.
041628 -        The 14-day period begins with the day the MA organization
041629 -        receives the request for expedited determination. [...see CMS
041630 -        regulation below, ref SDS 0 OY5N...]
041632 -  ..
041633 - This section may not apply, since Millie did not request expedited
041634 - review; except, the reviewing authority may have determined that
041635 - Millie's requirement for life saving care, required Expedited review,
041636 - per section 422.570 (c)(2). ref SDS 0 1U33
041638 -  ..
041639 - In any case, CMS regulation 422.570 (d)(1) cited in the CMS letter per
041640 - above, ref SDS 0 DO6S, appears to control response time for Expedited
041641 - Claims that have been denied. ref SDS 0 OY5N  On 100602, Eileen
041642 - advised that Kaiser did not deny Millie's claim. ref SDS 64 UN5P
041643 -
041644 -            [On 100628 0228 letter to claim teams asks how CMS
041645 -            regulations are applied for extending response to Millie's
041646 -            claim beyond 14 days cited in 422.570, and suggests another
041647 -            claim team conference call can clarify everyone is on
041648 -            track. ref SDS 93 KH8Y
041650 -             ..
041651 -            [On 100628 1033 during telecon Medicare advised that Kaiser
041652 -            verbally notified CMS, without notice to Millie, of having
041653 -            changed the classification of Millie's claim to a grievance
041654 -            procedure and as a result intends to delay until 100710,
041655 -            responding to Millie's claim filed on 100527, seeking
041656 -            emergency life-saving treatment. ref SDS 94 RO9X
041658 -             ..
041659 -            [On 100629 0003 Millie received from Medicare additional
041660 -            CMS regulations on timeframes for Kaiser to respond to her
041661 -            claim, ref SDS 95 6J4O, based on verbal representation
041662 -            during a call from CMS that Kaiser without notice changed
041663 -            the classification of Millie's claim to a grievance
041664 -            procedure, reported, 100628 1033, ref SDS 94 RO9X
041666 -  ..
041667 - CMS letter received from Cherry continues...
041668 -
041669 -    4.  Also,  you can read over 422.572 Timeframes and notice
041670 -        requirements for expedited organization determinations.
041672 -         ..
041673 -    5.  I hope this information helps. Let me know I you have
041674 -        additional questions.
041679 -         ..
041680 -    7.  Attachments....
041681 -
041682 -        a.  CMS 422.570............... ref SDS 0 4U5G
041683 -        b.  CMS 422.572............... ref SDS 0 C85I
041684 -
041685 -
041686 - ******************************************************
041688 -     ..
041689 -    Centers for Medicare & Medicaid Services, HHS
041690 -
041691 -    a.  CMS Regulations 422.570.....................Page 388
041692 -
041693 -              http://edocket.access.gpo.gov/cfr_2007/octqtr/pdf/42cfr422.570.pdf
041695 -         ..
041696 -        422.570                    42 CFR Ch. IV (10-1-09 Edition)
041697 -
041698 -        (d)  Written notice for MA Organization denials.
041700 -         ..
041701 -        If an enrollee requests an MA organization to provide an
041702 -        explanation of a practitioner's denial of an item or service,
041703 -        in whole or in part, the MA organization must give the enrollee
041704 -        a written notice.
041706 -         ..
041707 -        (e)  Form and content of the MA organization notice.
041709 -         ..
041710 -        The notice of any denial under paragraph (d) of this section
041711 -        must-
041712 -
041713 -        (1. Use approved notice language in a readable and
041714 -        understandable form;
041716 -         ..
041717 -        (2) State the specific reasons for the denial;
041719 -         ..
041720 -        (3) Inform the enrollee of his or her right to a
041721 -        reconsideration;
041723 -         ..
041724 -        (4)(i) For service denials, describe both the standard and
041725 -        expedited reconsideration processes, including the enrollee's
041726 -        right to, and conditions for, obtaining an expedited
041727 -        reconsideration and the rest of the appeal process; and
041729 -         ..
041730 -        (ii) For payment denials, describe the standard reconsideration
041731 -        process and the rest of the appeal process; and
041733 -         ..
041734 -        (5) Comply with any other notice requirements specified by CMS.
041736 -         ..
041737 -        (f) Effect of failure to provide timely notice.
041739 -         ..
041740 -        If the MA organization fails to provide the enrollee with
041741 -        timely notice of an organization determination as specified in
041742 -        this section, this failure itself constitutes an adverse
041743 -        organization determination and may be appealed.
041745 -         ..
041746 -        [65 FR 40329, June 29, 2000, as amended at 70 FR 4739, Jan. 28,
041747 -        2005; 70 FR 52027, Sept. 1, 2005]
041749 -         ..
041750 -        422.570 Expediting certain organization determinations.
041752 -         ..
041753 -        (a)Request for expedited determination.  An enrollee or a
041754 -        physician (regardless of whether the physician is affiliated
041755 -        with the MA organization) may request that an MA organization
041756 -        expedite an organization determination involving the issues
041757 -        described in  422.566(b)(3) and (b)(4). (This does not include
041758 -        requests for payment of services already furnished.)
041760 -             ..
041761 -        (b)How to make a request.
041762 -
041763 -            (1) To ask for an expedited determination, an enrollee or a
041764 -            physician must submit an oral or written request directly
041765 -            to the MA organization or, if applicable, to the entity
041766 -            responsible for making the determination, as directed by
041767 -            the MA organization.
041769 -             ..
041770 -            (2) A physician may provide oral or written support for a
041771 -            request for an expedited determination.
041773 -         ..
041774 -        (c) How the MA organization must process requests.
041776 -         ..
041777 -        The MA organization must establish and maintain the following
041778 -        procedures for processing requests for expedited
041779 -        determinations:
041781 -             ..
041782 -            (1) Establish an efficient and convenient means for
041783 -            individuals to submit oral or written requests.  The MA
041784 -            organization must document all oral requests in writing and
041785 -            maintain the documentation in the case file.
041787 -             ..
041788 -            (2) Promptly decide whether to expedite a determination,
041789 -            based on the following requirements:
041790 -
041791 -                (i) For a request made by an enrollee
041792 -                the MA organization must provide an
041793 -                expedited determination if it determines
041794 -                that applying the standard timeframe
041795 -                for making a determination
041796 -                could seriously jeopardize the life or
041797 -                health of the enrollee or the enrollee's
041798 -                ability to regain maximum function.
041799 -                 ..
041800 -                (ii) For a request made or supported
041801 -                by a physician, the MA organization
041802 -                must provide an expedited determination
041803 -                if the physician indicates that applying
041804 -                the standard timeframe for
041805 -                making a determination could seriously
041806 -                jeopardize the life or health of
041807 -                the enrollee or the enrollee's ability to
041808 -                regain maximum function.
041810 -         ..
041811 -        (d) Actions following denial.  If an MA organization denies a
041812 -        request for expedited determination, it must take the following
041813 -        actions:
041814 -
041815 -            (1) Automatically transfer a request to the standard
041816 -            timeframe and make the determination within the 14-day
041817 -            timeframe established in 422.568 for a standard
041818 -            determination.  The 14-day period begins with the day the
041819 -            MA organization receives the request for expedited
041820 -            determination.
041822 -             ..
041823 -            (2) Give the enrollee prompt oral notice of the denial and
041824 -            subsequently deliver, within 3 calendar days, a written
041825 -            letter that-
041826 -
041827 -                (i) Explains that the MA organization
041828 -                will process the request using the 14-
041829 -                day timeframe for standard determinations;
041830 -                 ..
041831 -                (ii) Informs the enrollee of the right
041832 -                to file an expedited grievance if he or
041833 -                she disagrees with the MA organization's
041834 -                decision not to expedite; and
041835 -                 ..
041836 -                (iii) Informs the enrollee of the right
041837 -                to resubmit a request for an expedited
041838 -                determination with any physician's
041839 -                support; and
041840 -                 ..
041841 -                (iv) Provides instructions about the
041842 -                grievance process and its timeframes.
041844 -         ..
041845 -        Centers for Medicare & Medicaid Services, HHS........Page 389
041847 -         ..
041848 -        (e)Action on accepted request for expedited determination.
041850 -         ..
041851 -        If an MA organization grants a request for expedited
041852 -        determination, it must make the determination and give notice
041853 -        in accordance with  422.572.
041855 -         ..
041856 -        (f) Prohibition of punitive action.  An MA organization may not
041857 -        take or threaten to take any punitive action against a
041858 -        physician acting on behalf or in support of an enrollee in
041859 -        requesting an expedited determination.
041861 -         ..
041862 -        [63 FR 35107, June 26, 1998, as amended at 65 FR 40329, June
041863 -        29, 2000; 70 FR 4739, Jan. 28, 2005]
041865 -         ..
041866 -    b.  422.572 Timeframes and notice requirements for expedited
041867 -        organization determinations.
041869 -         ..
041870 -        (a)Timeframe.  Except as provided in paragraph (b) of this
041871 -        section, an MA organization that approves a request for
041872 -        expedited determination must make its determination and notify
041873 -        the enrollee (and the physician involved, as appropriate) of
041874 -        its decision, whether adverse or favorable, as expeditiously as
041875 -        the enrollee's health condition requires, but no later than 72
041876 -        hours after receiving the request.
041878 -         ..
041879 -        (b)Extensions.
041881 -         ..
041882 -        The MA organization may extend the 72-hour deadline by up to 14
041883 -        calendar days if the enrollee requests the extension or if the
041884 -        organization justifies a need for additional information and
041885 -        how the delay is in the interest of the enrollee (for example,
041886 -        the receipt of additional medical evidence from noncontract
041887 -        providers may change an MA organization's decision to deny).
041888 -        When the MA organization extends the deadline, it must notify
041889 -        the enrollee in writing of the reasons for the delay and inform
041890 -        the enrollee of the right to file an expedited grievance if he
041891 -        or she disagrees with the MA organization's decision to grant
041892 -        an extension.  The MA organization must notify the enrollee of
041893 -        its determination as expeditiously as the enrollee's health
041894 -        condition requires, but no later than upon expiration of the
041895 -        extension.
041897 -         ..
041898 -        (c)Confirmation of oral notice.
041900 -         ..
041901 -        If the MA organization first notifies an enrollee of an adverse
041902 -        expedited determination orally, it must mail written
041903 -        confirmation to the enrollee within 3 calendar days of the oral
041904 -        notification.
041906 -         ..
041907 -        (d)How the MA organization must request information from
041908 -        noncontract providers.
041910 -         ..
041911 -        If the MA organization must receive medical information from
041912 -        noncontract providers, the MA organization must request the
041913 -        necessary information from the noncontract provider within 24
041914 -        hours of the initial request for an expedited organization
041915 -        determination.  Noncontract providers must make reasonable and
041916 -        diligent efforts to expeditiously gather and forward all
041917 -        necessary information to assist the MA organization in meeting
041918 -        the required timeframe.  Regardless of whether the MA
041919 -        organization must request information from noncontract
041920 -        providers, the MA organization is responsible for meeting the
041921 -        timeframe and notice requirements of this section.
041923 -         ..
041924 -        (e)Content of the notice of expedited determination.
041925 -
041926 -            (1)The notice of any expedited determination must state the
041927 -            specific reasons for the determination in understandable
041928 -            language.
041929 -
041930 -            (2)If the determination is not completely favorable to the
041931 -            enrollee, the notice must-
041932 -
041933 -                (i)Inform the enrollee of his or her right to a
041934 -                reconsideration;
041936 -                 ..
041937 -                (ii)Describe both the standard and expedited
041938 -                reconsideration processes, including the enrollee's
041939 -                right to request, and conditions for obtaining, an
041940 -                expedited reconsideration, and the rest of the appeal
041941 -                process; and
041943 -                 ..
041944 -                (iii)Comply with any other requirements specified by
041945 -                CMS.
041947 -         ..
041948 -        (f)Effect of failure to provide a timely notice.  If the MA
041949 -        organization fails to provide the enrollee with timely notice
041950 -        of an expedited organization determination as specified in this
041951 -        section, this failure itself constitutes an adverse
041952 -        organization determination and may be appealed.
041954 -         ..
041955 -        [63 FR 35107, June 26, 1998, as amended at 65 FR 40329, June
041956 -        29, 2000; 70 FR 4739, Jan. 28, 2005]
041958 -         ..
041959 -        422.574 Parties to the organization determination.
041960 -
041961 -        The parties to the organization determination
041962 -        are-
041964 -         ..
041965 -        (a)The enrollee (including his or her authorized
041966 -        representative);
041968 -         ..
041969 -        (b)An assignee of the enrollee (that is, a physician or other
041970 -        provider who has furnished a service to the enrollee
041971 -
041972 -
041973 -
041974 -
041975 -
041976 -
041977 -
041978 -
041979 -
041980 -
041981 -
041982 -
041983 -
0420 -