Provider Reimbursement Review Board Issues Alert 9 and Revised Rules

27 March 2013 Publication
Authors: Lawrence W. Vernaglia Chris E. Rossman Donald H. Romano

Legal News Alert: Health Care

On March 1, 2013, the Provider Reimbursement Review Board (PRRB or the Board) issued Alert 9, which notified interested parties that the PRRB has made revisions to its Rules and updated its Model Forms. Medicare providers that file appeals with the PRRB should review the revisions to ensure that their appeal filings and other documents comply with the Board’s revised requirements.

The rule revisions were effective on March 1, 2013, and apply to appeals pending as of, or filed on or after, March 1, 2013. The revised rules supersede the previously issued rules, which were last revised on July 1, 2009.

The rule revisions include the following:

  • Rule 3.3 now requires that copies of any documents submitted to the Board must simultaneously be served on the opposing party and the appeals support contractor.
  • Rule 5.1 includes a reminder that it is the responsibility of the provider’s representative to keep all contact information up to date, including the representative’s current email address, as the Board sends much of its correspondence by email.
  • Rule 7.1 changes the requirements for appeals from a Revised Notice of Program Reimbursement (Revised NPR), and requires the provider to submit additional documentation when submitting such appeals. Appeals from Revised NPRs must now include copies of the following: (a) the NPR that is immediately preceding the Revised NPR under appeal; (b) the Revised NPR; (c) the Reopening Request that preceded the Revised NPR (if applicable); (d) the Reopening Notice issued by the Intermediary or Medicare Administrative Contractor; (e) the Revised NPR workpapers for the issue or issues being appealed; and (f) any applicable cost report worksheets. The Board stated that it is requiring this information in order to determine whether the jurisdictional and filing requirements for an appeal involving a Revised NPR have been met.
  • Rule 9 states that if the provider representative has not received an Acknowledgement and Critical Due Dates Letter within 30 days of filing the appeal request, he or she should contact the Board.
  • Rule 16 requires additional documentation when a provider either transfers an issue from an individual provider appeal to a group appeal, or appeals an issue directly to a group appeal.
  • Rules 20.1 and 21 revise the requirements for the submission of the Schedule of Providers participating in a group appeal. Within 60 days of the full formation of a group, the providers’ representative must prepare and submit the Schedule of Providers, along with the jurisdictional documents that demonstrate that the Board has jurisdiction over the providers named in the group appeal, to the Board and the Lead Intermediary or Medicare Administrative Contractor. An additional copy of the Schedule of Providers (without the jurisdictional documents) must be sent to the appeals support contractor. The Board noted that these revised rules set forth different requirements for the Schedule of Providers than the previous rules, and further stated that failure to submit the requisite documentation for one of the providers may result in the dismissal of that provider from the group.

The Board also made revisions to its Model Forms, and requested that providers begin using the revised Model Forms as soon as possible. Providers should carefully review the revised Model Forms, because some of the Model Forms include requirements and instructions that are not set forth in the Rules.

PRRB Alert 9, the revised Rules, and the revised Model Forms can be accessed here:

For the past several years, the Centers for Medicare & Medicaid Services (CMS) has been recalculating the Medicare fraction (also known as the Supplemental Security Income (SSI) fraction) that is used to determine whether a hospital is entitled to receive Disproportionate Share Hospital (DSH) payments and, if so, the amount of those payments. It appears that CMS has completed these recalculations for many hospitals for certain cost reporting periods. Thus, it is likely that the Intermediaries and Medicare Administrative Contractors will be issuing numerous NPRs and Revised NPRs, with recalculated Medicare fractions and DSH payments, in the near future. In filing appeals, providers need to make sure that their appeal filings are in compliance with the Board’s revised requirements to ensure that their appeals will be accepted. 

Legal News Alert is part of our ongoing commitment to providing up-to-the-minute information about pressing concerns or industry issues affecting our health care clients and colleagues. If you have any questions about this Alert or would like to discuss this topic further, please contact your Foley attorney or any of the following individuals:

Jeffrey R. Bates
Los Angeles, California

Lawrence W. Vernaglia
Boston, Massachusetts

Donald H. Romano
Washington, D.C.

Chris E. Rossman
Detroit, Michigan

Related Services