Health Insurance Claim Number TRANSMITTAL NOTICEHEARING CASE Beneficiarys Name TO: Hearing Office (City and State) Applicants Name Type of Claim Date of Initial DeterminationFROM: Name and Address and Telephone Number of PRO/FI Date of Reconsideration Notice Date of Hearing RequestThis File Has Been Examined And We Find That: (Check Appropriate Block/s) 1. The documentation is adequate. 2. The documentation is not adequate to render a hearing decision. The necessary material has been requested and will be forwarded to you when received. 3. The sole issue appears to be whether your office has jurisdiction in this matter. Pursuant to section 1155 of the Social Security Act, the beneficiary has no right to a hearing as the amount in controversy is apparently less than $200. 4. Although the document is adequate, the request for hearing appears to be not filed timely. It should be first decided whether good cause for late filing exists. 5. A dismissal action is necessary since the beneficiary has no right to a hearing before a reconsideration determination has been rendered. We are initiating a reconsideration review of the claim for which the hearing was prematurely filed. 6. The reconsideration claim is currently being processed. Therefore, the appeal should be dismissed since the beneficiary has no right to a hearing before a reconsideration determination has been rendered. 7. A dismissal action is necessary since the PRO/FI has determined that there was no valid request for reconsideration and/or time frame to request same has expired. 8. Pursuant to section 1879(d) of the Social Security Act, the provider is determined to be liable and has filed for a hearing. The beneficiary is not exercising such appeal rights. 9. Although an appointment of Representative Form has been signed by the beneficiary, the provider cannot represent the beneficiary in appeals under Section 1155 of the Social Security Act. 10. A dismissal action is necessary since the provider has no right to the issue of medical necessity, reasonableness, and appropriateness of the setting in which services were furnished under Section 1155 of the Social Security Act and has no right to a hearing on the issue. 11. The sole issue appears to be whether your office has jurisdiction in this matter. Pursuant to section 1879 of the Social Security Act, the provider/beneficiary has no right to a hearing, as the amount in controversy is apparently less than $100. Remarks: ATTACHMENT, CLAIM FILE Date HA-5011-U6 Received In This Office X Approved Or Certified By: Title DateForm CMS-636(6/88)