Wednesday, October 21, 2015

How to file a cost report appeal with First Coast Medicare

Once a provider receives a notice of program reimbursement (NPR) from a cost report settlement, it has a right to redress audited adjustment related issues
through the cost report appeals process either as an individual or as a member of a group of providers before the provider reimbursement review board (PRRB).

Cost report appeal rights
Only a provider has appeal rights. Providers include.
 Hospitals
 Skilled nursing facilities (SNFs)
 Comprehensive outpatient rehabilitation facilities (CORFs)
 End-stage renal dialysis facilities (ESRDs)

Cost report appeal types

Providers may be a party to an individual appeal, a PRRB appeal or a group appeal.

 Intermediary appeal: Reimbursement in controversy is between $1,000 and $9,999.
 PRRB individual appeal: Reimbursement in controversy is $10,000 or more for individual providers.
Provider Reimbursement Manual, Part 1 (PRM15-1), paragraph 2920.1.

PRRB group appeal: Reimbursement in controversy, in aggregate is at least $50,000 and providers in the group have a common question of fact or of interpretation of
law, regulations or CMS rulings. Provider Reimbursement Manual Part 1, PRM15-1, paragraph 2920.2.

Deadline for filing request

The request for a hearing must be filed in writing with the PRRB or intermediary/Medicare administrative contractor (MAC) no later than the 180th calendar day following notice of the final determination rendered by the Centers for Medicare & Medicaid Services (CMS) or its MAC where the MAC has not issued the NPR timely, file the requests for a hearing with the Board no later than the 180th day after the expiration of the 12 month period. The audit adjustment(s) or issue(s) being appealed must be specific and directly related to the NPR.

Before filing your appeal hearing request, please obtain a copy of the PRRB’s rules from the PRRB’s website. Providers must follow the appeal process guidelines in the
PRRB instructions.

Once the PRRB or the MAC has acknowledged your appeal or hearing request, you must reference the assigned appeal case number and provide information on
all correspondence submitted to the PRRB or the MAC or Federal Specialized Services (FSS).

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