Current Alerts

ALERT 9:

REVISION OF PRRB RULES AND UPDATE OF PRRB MODEL FORMS

(March 1, 2013)

A.)  REVISION OF PRRB RULES

The Board has made revisions to the PRRB Rules (See Rules (and sub-rules) 3, 4, 5, 7, 9, 11, 12, 14, 15, 16, 20, 21, 22, 24, 27, 30, 37, and 44) updated July 1, 2009.  The revisions are effective March 1, 2013.  These instructions supersede those previously issued.  The changes to the PRRB Rules have been highlighted and dated with the effective date of the change. The PRRB Rules can be found at Instructions.

B.)  REVISION HIGHLIGHTS (but not limited to)

• Rule 3.3 now requires all Board correspondence be served on the opposing party AND the appeals supportcontractor (currently Blue Cross Blue Shield Association).
• Rule 5.1 includes a reminder that it the Representative’s responsibility to keep all contact information up to date with the Board, including the current e-mail address, as correspondence is frequently issued by the Board electronically.
• Rule 7.1 requires that when appealing a Revised NPR, additional documentation is now required to support that the issue under appeal was revised in the Revised NPR pursuant to 42 C.F.R. § 405.1889.
• Rule 16 adds additional documentation requirements when Filing a Form D to transfer an issue from an individual appeal to a group appeal as well as when filing a Form E tofile directly from a Final Determination into a group appeal.
• Rule 20.1 requires Schedules of providers with supporting documentation to be sent simultaneously to the Lead Intermediary and the Board.
• Rule 21 has been significantly revised to include additional informational requirements on the Schedule of Providers (Schedule G) and additional supporting documentation requirements.
• Rule 27.6 requires the additional 5 copies of final position papers to be submitted to the Board 7-10 business days prior to a Board hearing.

C.)  UPDATE OF PRRB MODEL FORMS

We have updated the PRRB model forms to incorporate the changes made to the Board Rules.  Please begin using the revised model forms as soon as possible.  We have also converted the revised model forms to a fillable PDF format, which can be found at Instructions.

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ALERT 8:

TRANSFERRING ISSUES

(December 8, 2011)

Effective immediately, the Board requires that the following supporting documentation be attached to a request to transfer an issue from an individual appeal to a group appeal:

*  If the issue was included in the Provider's initial individual appeal request, you MUST attach a copy of the initial appeal request showing the issue was included in the original appeal to either your transfer request letter or Model Form D – Request to Transfer an Issue to a Group Appeal.

*  If the issue was added to the Provider's pending individual appeal after the initial hearing request, you MUST attach a copy of the letter and/or a copy of the Model Form C (Request to Add Issue(s) to an Individual Appeal) you originally submitted to add the issue, to your transfer request letter or Model Form D – Request to Transfer an Issue to a Group Appeal.

In addition, the Board has revised Model Form D (Request to Transfer an Issue to a Group Appeal), to incorporate these new requirements.  You can download the revised Model Form D at Instructions.

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ALERT 7:

PROCEDURES FOR IMPLEMENTING CMS RULING NO. CMS-1498-R

(May 25, 2010)

The Provider Reimbursement Review Board (Board) requests your assistance in identifying all cases and/or issues pending in cases impacted by the Centers for Medicare & Medicaid Services Ruling No. CMS-1498-R (CMS-1498-R), which provides for a recalculation of your disproportionate share hospital (DSH) payment adjustment.  You can view CMS-1498-R under at http://cms.gov/Regulations-and-Guidance/Guidance/Rulings/downloads/CMS1498R.pdf

The Ruling addresses three issues: (1) SSI fraction data matching process, (2) dual eligible days (“days where the patient was entitled to Part A benefits but the … stay was not covered under Part A or … benefits were exhausted” (See CMS-1498-R at p. 11), and (3) labor/delivery days.  If you have issues governed by the Ruling you will not be required to meet the due dates (including briefing and hearing dates) for those issues; however, you are still required to meet those due dates for all other issues remaining in the case.  The following procedures apply:

DEADLINES

*  On or before the position paper deadline:

(1)  Submit a letter to the Board and Intermediary

*  identifying those issue(s) in your case that are governed by CMS-1498-R and therefore will not be briefed, and

*  to assist the Board in prioritizing, we would appreciate your advising us which remand procedure you prefer.

(2)  Brief the remaining issues, if any, in accordance with the Board's rules.  If in doubt about whether your issue is governed by the Ruling, brief it and include your position as to why it is or is not covered.

*  At least 30 days prior to the hearing date:  Advise the Board and Intermediary in writing of issues or cases that will not require a hearing because they are governed by the Ruling.  If you have not already received or requested a remand for the issues governed by the Ruling, state which remand procedure you select.

REMANDS

*  You may request a remand of the case (including groups) or an issue governed by the Ruling beginning immediately under either the “alternative procedure” described at page 19 of the Ruling, or the “standard procedure” described at page 18.

*  To assist the Board in expediting these requests, please put “REMAND REQUEST” and either “ALTERNATIVE PROCEDURE” or “STANDARD PROCEDURE” in the subject line.

*  If you select the alternative procedure, refer to Section 4.C of the Ruling for provider responsibilities under the alternative implementation procedure.  If you select the standard procedure, the Board will review jurisdiction based on the documentation in the record or, if necessary, will send a request for additional documentation.  Providers should have documentation readily available that is sufficient to show jurisdiction (timely filing, dissatisfaction, and amount in controversy) and to support the Schedule of Providers.

*  In order to process remands for as many cases as possible, requests under the alternative procedure will be given priority.  Without a request, the Board will review jurisdiction and remand under the “standard procedure” as expeditiously as possible in the regular course of business.

*  Group appeals, including CIRPs, may request remand even if the group is incomplete.

If you have a question not answered by this Alert, send us a letter (no e-mails or telephone calls, please) setting out the circumstances and your question with a copy to the Intermediary/MAC.  Be aware that the Board does not have any information about the Intermediary/MAC process or timelines beyond what is stated in the Ruling.  It is our understanding that CMS will be issuing further instructions to the Intermediaries/MACs regarding implementation in the near future.

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ALERT 6:

BAYSTATE MEDICAL CENTER v. SHALALA

(March 23, 2010)

The Board is aware that the decision in Baystate Medical Center v. Shalala, 587 F.Supp. 2d 37 (D.D.C. 2008) (Baystate) has become final.  The Board has placed many cases in abeyance for Baystate  and directed providers to notify the Board within 60 days of the conclusion of the case if the cases in abeyance need to proceed to a hearing or if a settlement is expected. THIS NOTICE IS TO ADVISE PROVIDERS THAT HAVE CASES IN ABEYANCE PENDING A FINAL BAYSTATE DECISION THAT IT WILL NOT BE NECESSARY TO CONTACT THE BOARD REGARDING THE FINAL OUTCOME OF BAYSTATE. However, if jurisdictional documents have not been furnished to the Intermediary or the Board, we encourage you to do so promptly.  The Board will notify providers when additional action will be necessary.

All prior alerts are available by download below.