At the discretion of DHA, certain
cases appealed may be returned to the contractor for processing
without the issuance of a formal review or hearing decision. These
cases will normally involve instances in which a processing error
has resulted in a denial or partial denial of a claim; instances
in which the contractor has failed to obtain additional documentation
as required by
paragraph 4.3; instances in which the contractor
has failed to address the entire EOC; instances in which the contractor
has erroneously identified a medical necessity issue as a factual
issue and visa-versa; instances in which the contractor has failed
to complete the Appeal Summary Log; and instances in which the contractor
has failed to offer appropriate appeal rights. Also, DHA, in doing
normal development associated with the appeal process, may obtain
information that resolves the issues without further review by DHA.
If the case is returned for reprocessing, for record purposes the
case will be treated as a new request for reconsideration (i.e.,
Chapter 1, Section 3, paragraph 4.0, will
apply and the returned case will be reported for workload purposes).
Development for additional documentation, if necessary, will be
performed as it would in any reconsideration case. The contractor
shall issue a revised reconsideration determination based on the
merits of the claim. If applicable, additional appeal rights shall
be offered by the contractor.