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Last Modified: 11/1/2021 Location: FL, PR, USVI Business: Part A

Cost report appeals

Once a provider receives a Notice of Program Reimbursement (NPR) from a cost report settlement, it has a right to redress audited adjustment related issues through the cost report appeals process either as an individual or as a member of a group of providers before the Provider Reimbursement Review board (PRRB).

Cost report appeal rights

Only a provider has appeal rights. Providers include.
Hospitals
Skilled nursing facilities (SNFs)
Comprehensive outpatient rehabilitation facilities (CORFs)
End-stage renal dialysis facilities (ESRDs)

Appeal types

If you wish to dispute the amount due the provider, you may file a Medicare Administrative Contractor (MAC) appeal (also known as an Intermediary appeal) or a Provider Reimbursement Review Board (PRRB) appeal. The following table illustrates the criteria for filing a MAC appeal or PRRB appeal for individual or group cases based on the amount in controversy.

Appeal type
Amount in Dispute for MAC Appeals
(42CFR 405.1809 -
405.1833)
Amount in Dispute for PRRB Appeals (42CFR 405.1809 -
405.1883)
Individual Providers
$1,000 - $9,999
$10,000 or more
Group
No provision for group appeals $10,000 or more
$50,000 or more, in aggregate; no minimum for individual providers

Filing deadlines

All appeals must be received within 180 calendar days of the date of the provider's receipt of the NPR (or within 185 calendar days of the date of the NPR) and must include:
Identification of the items in dispute, by adjustment number, amount and description.
The reason(s) you disagree with the MAC's determination on these items.
One copy of the NPR, or the determination(s) disputed and the corresponding section(s) of the adjustment report.
Appeals must also include an estimate of the correct reimbursement for each item in dispute.

Electronic filing

Per PRRB Rule 2.1 - OH CDMS is a web-based portal for parties to enter and maintain their cases and to correspond with the PRRB. Access to the system is granted as needed based on role. Access to specific cases is limited to the parties of each case, including party representatives.
The webpage includes a link to the CMS Enterprise Portal as well as current registration and user manuals. For any technical system issues, please contact the OH CDMS Help Desk at 1-833-783-8255 or email helpdesk_ohcdms@cms.hhs.gov.

Filing outside of OH CDMS

For MAC appeals or for PRRB Appeals granted an exemption under Board Rule 2.1.2, send as directed below:

 
For MAC Appeals
For PRRB Appeals
Original
PRRB Appeals
Federal Specialized Services 1701 S. Racine Avenue Chicago, IL 60608-4058
Chairman
Provider Reimbursement Review Board
CMS Office of Hearings
7500 Security Boulevard
Mail Stop: B1-01-31
Baltimore, MD 21244-1850
Copy
JN Provider Audit & Reimbursement
First Coast Service Options
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
PRRB Appeals
Federal Specialized Services
1701 S. Racine Avenue
Chicago, IL 60608-4058 prrb@fssappeals.com
JN Provider Audit & Reimbursement
First Coast Service Options
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
For more information on filing an appeal with the MAC, please contact PRRBAppeals@fcso.com
For more information on filing an appeal with the PRRB, please reference https://www.cms.gov/Regulations-and-Guidance/Review-Boards/PRRBReview/indexexternal link
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.