Skip to Main Content

Low Volume Appeals Initiative

What's New

6/7/2018 - As a reminder, the last day to submit an Expression of Interest for the Low Volume Appeals Initiative is June 8, 2018.  Details about the process, including a fillable Expression of Interest Form, are available in the downloads section below.

4/16/2018 - Appeal Eligibility Clarification - Appeals that involve items, services, drugs, or biologicals billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes (e.g., CPT Code 38999 – Unlisted procedure, hemic or lymphatic system; K0108 – Wheelchair component or accessory, not otherwise specified) are not eligible for settlement under the Low Volume Appeals settlement process.

FAQs Update – An FAQ regarding the appeal eligibility clarification has been added to LVA FAQ document in the Downloads section below.

3/29/2018 - The deadline to submit an expression of interest (EOI) for the Low Volume Appeals (LVA) Initiative is being extended to June 8, 2018.  Appellants with either an odd or an even NPI, that meet the eligibility criteria, should submit an EOI between April 12, 2018 and June 8, 2018.  Details about the process, including a fillable EOI, are available in the downloads section below.

2/28/2018 - New FAQ added.

2/23/18 - March 9, 2018 is the last day for appellants with National Provider Identifiers (NPIs) ending in an even number (0, 2, 4, 6, 8) to submit an expression of interest (EOI) for the Low Volume Appeals (LVA) Initiative.  

From March 12, 2018 through April 11, 2018, appellants with NPIs ending in an odd number (1, 3, 5, 7, 9) can submit their expressions of interest.  Appellants with both odd and even NPIs should submit one EOI per NPI during these designated timeframes.  Details about the process, including a fillable expression of interest, are available in the downloads section below.

On March 13th, 2018, CMS will host a Medicare Learning Network Provider Call to discuss the settlement process, how to identify whether you are eligible, and which of your pending appeals may be settled.  The registration for the March 13th call can be found at https://blh.ier.intercall.com/catalog.

CMS hosted other Medicare Learning Network Provider Calls on the LVA settlement.  The written transcripts and audio recordings for those calls are available at: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=descending

Overview

Beginning February 5, 2018, CMS will start 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.

Specifically, CMS will make available an administrative settlement process for appellants with fewer than 500 appeals pending at OMHA and the Council, combined, as of November 3, 2017, to settle the portion of their pending appeals that have total billed amounts of $9,000 or less per appeal in exchange for timely partial payment of 62% of the net Medicare approved amount.

To begin the process, appellants must complete and submit an Expression of Interest (EOI) as explained below.

Eligibility

Eligible appellants are:

Medicare Part A and Part B providers, physicians, and suppliers with fewer than 500 appeals pending at OMHA and the Council, combined, and that do not fit into one or more of the categories of “ineligible appellants” listed below.

Ineligible appellants are:

  • Beneficiaries, enrollees, their family members, or estates. 
  • State Medicaid Agencies.
  • Medicare Advantage Organizations (Medicare Part C).
  • Those that filed for bankruptcy or expect to file for bankruptcy. 
  • Certain appellants that have or have had False Claims Act litigation or investigations pending against them, or other program integrity concerns, including pending civil, criminal, or administrative investigations. 

Eligible appeals are appeals meeting all of the following criteria: 

  1. The appeal was pending before the OMHA and/or Council level of appeal as of November 3, 2017;
  2. The appeal has a total billed amount of $9,000 or less;
  3. The appeal was properly and timely filed at the OMHA or Council level as of November 3, 2017;
  4. The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system;
  5. The claims included in the appeal were submitted for payment under Medicare Part A or Part B;
  6. The claims included in the appeal were not part of an extrapolation; and,
  7. As of the date this Agreement is fully executed, the appeal was still pending at the OMHA or Council level of review.

If an appellant’s National Provider Identifier (NPI) is approved for participation in this process, the resulting settlement will apply to all eligible appeals from that appellant. The appellant cannot choose to settle some eligible appeals but not others.

Settlement Process

The detailed settlement process is outlined in the Downloads section below.

The settlement process is initiated by the appellant submitting their Expression of Interest (EOI) to CMS at MedicareAppealsSettlement@cms.hhs.gov. Appellants with multiple NPIs will be required to submit one EOI per NPI with eligible appeals.

If the appellant is approved for participation, CMS will send the appellant (1) a Spreadsheet of potentially eligible appeals and the associated claims (Spreadsheet) for the appellant’s review; and (2) an Administrative Agreement (Agreement).  The appellant will validate the Spreadsheet and sign and return the Agreement to CMS. CMS will counter sign and send a copy of the fully executed Agreement to the appellant.

If, during validation, the appellant discovers discrepancies on the Spreadsheet, the appellant must notify CMS by submitting an Eligibility Determination Request (EDR) to CMS at MedicareAppealsSettlement@cms.hhs.gov within 15 calendar days of receiving the package containing the Spreadsheet and Agreement.  

CMS and the appellant have 30 days to resolve any discrepancies. If discrepancies are resolved, the appellant will sign and return the Agreement to CMS. CMS will counter sign and send a copy of the fully executed Agreement to the appellant.

At any time prior to the appellant returning the signed Agreement, the appellant may withdraw from the process and will retain full appeal rights. Proceedings on all eligible pending appeals will be stayed once the appellant returns the signed Agreement. 

Expression of Interest Period 

To ensure timely processing, CMS has designated specific EOIs submission windows, based on NPI. 

  • For appellants with NPIs ending in an even number (0, 2, 4, 6, 8), EOIs will be accepted on February 5, 2018 through March 9, 2018.
  • For appellants with NPIs ending in an odd number (1, 3, 5, 7, 9), EOIs will be accepted on March 12, 2018 through April 11, 2018.
  • For all appellants, EOIs will be accepted between April 12, 2018 and June 8, 2018.

Appellants with both odd and even NPIs will be required to submit one EOI per NPI during the appropriate designated timeframe, as described above.

To request participation in the process, appellants must complete the EOI and submit it to MedicareAppealsSettlement@cms.hhs.gov.

Additional Information 

See the Downloads section below for the most recent Frequently Asked Questions or email your questions to MedicareSettlementFAQs@cms.hhs.gov. CMS may post and periodically update the Frequently Asked Questions about this settlement process. 

.