Provider Appeal Requests - PRRB or Contractor Hearings

Provider Reimbursement Review Board (PRRB) Appeal Requests

Part A Providers are guaranteed the right to Appeal (42 USC 1395ooetseq) any "final determination" (NPR) with which they are "dissatisfied", providing the issue meets specific criteria of dissatisfaction, timeliness of appeal (within 180 days) and amount in controversy ($10,000 individual appeal; $50,000 group appeal). The appeal is to the Provider Reimbursement Review Board (PRRB), an independent adjudicating body of DHHS, staffed by the Office of Hearings of CMS, which serves as the "final exhaustion of administrative remedy" (Administrative Procedures Act §704) for the Provider that allows the Provider to move into the judicial system if appeal is rejected by the PRRB or CMS Administrator (oversight of PRRB). PRRB Rules

A PRRB appeal may be filed two ways: electronically through the Office of Hearings Case and Document Management System (OH CDMS) or through a hard copy submission.

While the electronic way is not currently required, the PRRB strongly recommends all parties use this new electronic case management tool. To access OH CDMS, see the CMS Electronic Filing webpage. The webpage includes a link to the CMS Enterprise Portal as well as current registration and user manuals.

To file a hard copy PRRB appeal request, direct your appeal to:

Chairperson
Provider Reimbursement Review Board
1508 Woodlawn Drive, Suite 100
Baltimore, MD 21207
410-786-2671

A copy of the PRRB appeal request and subsequent correspondence should be sent to Noridian via email JFPRRBAppeals@Noridian.com as well as to Federal Specialized Services, LLC (FSS) via email prrb@fssappeals.com. In the subject line, reference the case number first (if available), followed by the case name, followed by the nature of the correspondence. There is no need to send a paper copy.

Contractor Appeal Hearing Requests

If a provider takes exception to adjustments whereby the effect on Medicare reimbursement is at least $1,000 but less than $10,000, the provider can request a Contractor appeal hearing. A Contractor appeal must be addressed to Federal Specialized Services, LLC (FSS) via email intermediary@fssappeals.com.

When email is not an option, providers filing Contractor appeals should send their documents via U.S. mail or express delivery services to the following FSS address.

PRRB Appeals/Contractor Appeals
Federal Specialized Services, LLC
1701 S. Racine Avenue
Chicago, IL 60608-4058

A copy of the appeal request and any subsequent correspondence should also be sent to Noridian via email at JFPRRBAppeals@Noridian.com.

Please do not send any Protected Health Information (PHI) or Personally Identifiable Information (PII). Files containing PHI or PII will be returned to the sender.

Should you need additional information regarding appeals, as well as the requirements for an appeal request, information is available at 42 CFR 405.1809, 405.1811, 405.1815, 405.1835, 405.1843 and the PRRB Rules, Version 2.0, dated August 29, 2018.

 

Last Updated Mar 26, 2019