skills/medicare-notice-triage/references/triage-routing.md

# Triage and routing reference

## Identify before advising

Extract exact wording for:

- issuer and contractor type;
- audit/review program;
- synthetic episode and claim labels rather than claim numbers or beneficiary identifiers;
- dates of service and services at issue in de-identified form;
- stated denial or documentation issues;
- response or appeal rights;
- deadline and delivery method;
- recoupment or offset language; and
- representative or signature requirements.

If direct identifiers appear, do not continue record-specific analysis. Ask for a de-identified version using synthetic labels, relative episode days, and year-only dates when possible. Do not treat consistently shifted calendar dates as Safe Harbor de-identification.

## Common routing distinctions

- An ADR requests documentation for medical review; it is not itself necessarily an appeal decision.
- A claim correction or reopening can differ from an appeal. Do not select the route until the notice and current contractor instructions are checked.
- The standard Original Medicare Part A/B appeal sequence is redetermination, QIC reconsideration, OMHA/ALJ, Medicare Appeals Council, and federal district court. Monetary thresholds and deadlines can change and must be verified for the relevant year and notice.
- Medicare Advantage (Part C) begins with plan organization-determination and reconsideration processes and uses a Part C Independent Review Entity rather than a MAC and QIC. Eligible parties may later reach OMHA/ALJ, Council, and court review, but party status, forms, deadlines, automatic IRE forwarding, and contracted-provider rules differ. Route from the plan notice and current Part C guidance; never reuse fee-for-service instructions.
- Contractor dismissals can have special review or vacatur paths. Read the dismissal notice rather than assuming ordinary merits appeal rights.

## Deadline discipline

For every due date:

1. Quote or accurately paraphrase the notice's timing rule.
2. Identify the triggering date.
3. Show the calendar arithmetic and any receipt presumption only with permitted dates. Otherwise calculate relative time: for a synthetic 30-day-from-receipt rule with 7 days elapsed, show 30 - 7 = 23 days provisionally remaining. Do not request identifying dates or fabricate a calendar due date. The user verifies the actual calendar deadline in the approved workspace.
4. State whether weekends, holidays, good-cause rules, or electronic portal cutoffs were verified.
5. Recommend filing early enough to preserve proof of timely delivery.

Track response/appeal deadlines separately from any shorter recoupment-protection deadline. State when the rule or counting convention is unverified. Resolve conflicting notice/authority instructions with the contractor or qualified adviser promptly; do not silently choose a longer deadline.

## Sources

- CMS Original Medicare fee-for-service appeals: https://www.cms.gov/medicare/appeals-grievances/fee-for-service
- CMS redetermination guidance: https://www.cms.gov/medicare/appeals-grievances/fee-for-service/first-level-appeal-redetermination-medicare-contractor
- CMS ADR overview: https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request
- CMS Medicare Advantage appeals: https://www.cms.gov/medicare/appeals-grievances/managed-care