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Medicare Low Volume Appeal Settlement

Medicare Low Volume Appeal Settlement - Don't Miss Your Opportunity

Do you have Medicare Appeals pending at the Office of Medicare Hearing and Appeals (OHMA)? If yes, this is a very important announcement for you from CMS.

Settlement Offer

On February 5, 2018, CMS will begin accepting Expressions of Interest (EOIs) for a limited settlement agreement option for Medicare Fee-For-Service providers, physicians, and suppliers (appellants) with fewer than 500 appeals pending at the Office of Medicare Hearing and Appeals (OMHA) and the Medicare Appeals Council (Council) at the Departmental Appeals Board. CMS will settle the portion of their pending appeals that have total billed amounts of $9,000 or less per claim in exchange for timely partial payments of 62% of the net Medicare approved amount.

To be Eligible:

  • Claim must be denied and in a pending status with OMHA appeals. It must meet timely filing requirements as stated by the OMHA.
  • Provider cannot submit a single line item denial, the entire claim must be denied (all services for that date).
  • Total charges on a single claim cannot exceed $9000.00
  • Total number of claims cannot exceed 500. Settlement applies to 500 or under claims as of November 3, 2017 that are in a pending status. If you have multiple NPIs, totals are calculated collectively for all NPIs linked to a single provider.
  • NPI cannot be linked to an investigation, litigation, or any other program-integrity concern including civil, criminal, or administrative investigations. It excludes providers that have filed for bankruptcy or intend to file.
  • Claim cannot be a Medicare Advantage Plan claim.
  • Claim appeal cannot be related to part of an extrapolation.

Initial Steps

Follow these instructions carefully.

EOIs submitted outside the above defined timeframes will result in rejection of the EOI. Appellants with both odd and even NPIs are required to submit one EOI per NPI in the appropriate designated timeframes, as described above.

  1. Determine which application submission date applies to you. For appellants (providers) with NPIs ending in:
    • Even numbers (0, 2, 4, 6, 8), EOIs will be accepted between February 5, 2018 and March 9, 2018.
    • Odd number (1, 3, 5, 7, 9), EOIs will be accepted between March 12, 2018 and April 11, 2018.

      EOIs submitted outside the above defined timeframes will result in rejection of the EOI. Appellants with both odd and even NPIs are required to submit one EOI per NPI in the appropriate designated timeframes, as described above.
  2. Complete and submit the Expression of Interest (EOI) found here

    NOTE: If you (the appellant) have more than one NPI you must file an EOI for each one. Collectively you must have fewer than 500 pending denied claims filed for all NPIs to qualify.
  3. Submit the completed EOI via email to MedicareAppealsSettlement@cms.hhs.gov. Include the following in the Subject of Email: Provider Name-NPI-expression of interest.

NOTE: Check submission dates prior to sending (see step 1)

Approval

If an EOI is approved for participation, CMS will send the appellant:

  • A Spreadsheet of potentially eligible appeals and the associated claims (spreadsheet) for the appellant’s review.
  • An Administrative Agreement (Agreement).

Provider Review

The clock is ticking. Once you receive the Spreadsheet and Agreement you must review and submit the necessary information within 15 days of receipt.

If you agree with all the claims listed and they match your records (validate the spreadsheet), sign and return the Agreement to CMS. CMS will counter sign and send a copy of the fully-executed Agreement to the appellant. You will then receive payment within 180 days from the date of the executed agreement.

If you disagree during validation and/or you discover discrepancies on the spreadsheet, the appellant (provider) must notify CMS by submitting an Eligibility Determination Request (EDR) to CMS. Send the notification to: MedicareAppealsSettlement@cms.hhs.gov within 15 calendar days of receiving the spreadsheet and Agreement.

Example 1: You find claims on the Spreadsheet that should not be linked to your NPI due to a TIN ownership change. This error could put you over the 500-claim limit. Note the error on the EDR form (see Fig. 1) below:

Low Volume Appeal Settlements

Example 2: You find claims on the spreadsheet that should not be included because they have been settled. Request to have them removed using the EDR form (see Fig. 2) below:

Low Volume Appeal Settlements

If claims are missing from the spreadsheet, you should list each one individually on the EDR form.

Once discrepancies are resolved, the appellant signs and returns the Agreement to CMS at MedicareAppealsSettlement@cms.hhs.gov. CMS will counter sign and send a copy of the fully executed Agreement to the appellant. Payment will be sent within 180 days of receipt of the Agreement.

Note: The appellant can withdraw from the process and retain full appeal rights at any time before the appellant returns the signed Agreement. Proceedings for all eligible pending appeals are stopped once the appellant returns the signed Agreement. All documents sent via email are encrypted by CMS. Check email settings for encryption capabilities prior to submitting protected health information.

Helpful Websites and Email Addresses:

Resource

Website/Email Address

LVA

http://go.cms.gov/LVA

LVA Submissions

CMSMedicareAppealsSettlement@cms.hhs.gov

LVA Questions

MedicareSettlementFAQs@cms.hhs.gov

Flowchart

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Appeals-Settlement-Initiatives/LVA-Process-Flow-Diagram.pdf

EQI Form

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Appeals-Settlement-Initiatives/LVA-External-Fillable-Expression-of-Interest.pdf

EDR Form

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Appeals-Settlement-Initiatives/LVA-Process-Flow-Diagram.pdf

OMHA Settlement Facilitation Conference

https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlement-conference-facilitation/index.html

Acronyms and Definitions:

Acronym

Definition

LVA

Low Volume Appeals Settlement

OMHA

Office of Medicare Hearing and Appeals Council

NPI

National Provider Identifiers

EOI

Expression of Interest

EDR

Eligibility Determination Request

MAC

Medicare Administrative Contractor

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