Provider Appeal Requests - PRRB or Contractor Hearings - JF Part A
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 Review
Effective November 1, 2021, a PRRB appeal request must be submitted electronically through the Office of Hearings Case and Document Management System (OH CDMS). In limited circumstances, it may be necessary for a party to contact the PRRB to request an exemption to the mandatory electronic filing requirement, as described in PRRB Rule 2.1.2. PRRB Rules
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.
When a provider appeal request is submitted through the OH CDMS, the system automatically notifies all parties to the appeal, including Noridian and Federal Specialized Services, LLC.
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 firstname.lastname@example.org.
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 3.1, effective November 1, 2021.
Last Updated Fri, 15 Oct 2021 19:36:17 +0000