3.8.1 Initial Denial Determinations
(Other Than Reconsiderations of Concurrent Review)
The contractor shall follow
the reconsideration procedures below:
• Provide
advance notice of the date that the reconsideration determination
will be issued to allow sufficient time for the preparation and
submission of additional information.
• Reschedule the reconsideration
if a party submits a written request presenting a reasonable justification
for rescheduling.
• A reconsideration determination
shall be based on the information that led to the initial determination,
all information found in the medical record, and additional information
submitted by the beneficiary or provider. If the beneficiary or
provider fails to submit requested additional documentation, the
reconsideration determination will be based on the available documentation.
• The beneficiary or provider
must present the additional information in writing.
• Parties
shall be informed that they will receive written notification of
the reconsideration determination after the contractor has reviewed
the case.