Denials/Appeal Rights
What actions will be taken if the attestation (i.e., determination of provider-based status) is denied?
In accordance with §413.65(k), recovery of overpayments will be made from the date of the disapproval of the attestation back to the date on which the provider submitted the attestation. In addition, the Regional Office should issue a notice of denial of provider-based status to the provider explaining that the provider has the following 3 options:
(1) The provider may notify CMS in writing within 30 days of the date the notice is issued that the provider intends to make the changes needed for the facility or organization to comply with the provider-based rules and that the provider intends to seek a determination of provider-based status for its facility or organization. If the provider indicates that it will be seeking a provider-based determination for the facility or organization, then CMS will continue to pay for services provided at the facility or organization at a rate estimated for services furnished by a freestanding facility. CMS will continue to pay at this rate for as long as is required for the facility or organization to comply with the provider-based rules, (but not for longer than 6 months), if the provider submits a complete request (not an attestation) for a provider-based determination and all other required information within 90 days after the date of the notice of denial of provider-based status. If the necessary application or information is not provided, CMS will terminate all payment to the provider, facility, or organization as of the date CMS issues notice that necessary applications or information have not been submitted.
(2) The provider may notify CMS in writing within 30 days of the date the notice is issued that the facility or organization (or, where applicable, the practitioners who staff the facility or organization) will be seeking to enroll and meet other requirements to bill for services in a free-standing facility. If the provider indicates that the facility or organization, or its practitioners, will be seeking to meet enrollment and other requirements for billing for services in a free-standing facility, then CMS will continue to pay for services provided at the facility or organization at a rate estimated for services furnished by a freestanding facility. CMS will continue to pay at this rate for as long as is required for the facility or organization to enroll as a freestanding facility, (but not for longer than 6 months), if the facility or organization, or its practitioners, submit a complete enrollment application and furnish all other information needed by CMS to process the enrollment application and verify that other billing requirements are met within 90 days after the date of notice of the denial of provider-based status. If the necessary enrollments or information is not provided, CMS will terminate all payment to the provider, facility, or organization as of the date CMS issues notice that necessary applications or information have not been submitted.
(3) The provider may choose not to notify CMS within 30 days of the date the notice is issued of whether it intends to pursue provider-based status under item (1) above, or freestanding status under item (2) above. If CMS does not receive a response as described in item (1) or item (2) within 30 days of the date the notice is issued, all payment will end as of the 30th day after the date of the notice.
Regardless of whether or how it responds to the notice in items (1) through (3) above, the provider may choose to appeal its denial of provider-based status within 60 days from the date of the notice of denial. Adverse determinations regarding provider-based status may be appealed under the administrative appeals procedures set forth in 42 CFR Part 498. Any notice to the provider, from Centers for Medicare & Medicaid Services (CMS) Regional Office, of an adverse determination must contain a paragraph informing the provider of its right to appeal under those procedures. The following language may be used to inform the provider of its appeal rights:
Initial Determination Request for Reconsideration
If you are dissatisfied with this determination, you may request reconsideration by filing a written reconsideration request within sixty (60) days from the date on which you receive this letter. Your request must state the issues or findings of fact with which you disagree and the reasons for disagreement. Your reconsideration rights are set forth in the regulations at 42 CFR §498.22. Please address your request for reconsideration to:
CMS will include the appropriate CMS Regional Office for which State the parent provider resides in
Denial of a Reconsideration Request
If you disagree with this first level appeals determination, you or your legal representative may request a hearing before an Administrative Law Judge (ALJ) of the Department of Health and Human Services, Departmental Appeals Board. Procedures governing this process are set out in the regulations at 42 CFR §498.40 et seq. A written request for a hearing must be filed within sixty (60) days from the date on which you receive your first level appeal results. The request should be made to:
Departmental Appeals Board
Civil Remedies Division
Room 637-D
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
Attention: Jacqueline Williams
Forward a copy of your request for an ALJ hearing to:
CMS will include the appropriate CMS Regional Office for which State the parent provider resides in
and
CMS will include the appropriate Regional Office General Counsel
A request for a hearing must identify the specific issues and findings of fact and conclusions of law with which you disagree, and specify the basis for contending that the findings and conclusions are incorrect.
Page Last Updated: Tuesday, 29-Dec-2009 13:35:54 CST
