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Last Modified: 10/2/2018 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)

Cost report appeal types

Providers may be a party to an individual appeal, a PRRB appeal or a group appeal.
Intermediary appeal: Reimbursement in controversy is between $1,000 and $9,999.
PRRB individual appeal: Reimbursement in controversy is $10,000 or more for individual providers. Provider Reimbursement Manual, Part 1 (PRM15-1), paragraph 2920.1 compressed file.
PRRB group appeal: Reimbursement in controversy, in aggregate is at least $50,000 and providers in the group have a common question of fact or of interpretation of law, regulations or CMS rulings. Provider Reimbursement Manual Part 1, PRM15-1, paragraph 2920.2. compressed file.

Deadline for filing request

The request for a hearing must be filed in writing with the PRRB or intermediary/Medicare administrative contractor (MAC) no later than the 180th calendar day following notice of the final determination rendered by the Centers for Medicare & Medicaid Services (CMS) or its MAC where the MAC has not issued the NPR timely, file the requests for a hearing with the Board no later than the 180th day after the expiration of the 12 month period. The audit adjustment(s) or issue(s) being appealed must be specific and directly related to the NPR.
Before filing your appeal hearing request, please obtain a copy of the PRRB’s rules external link from the PRRB’s website. Providers must follow the appeal process guidelines in the PRRB instructions.
Once the PRRB or the MAC has acknowledged your appeal or hearing request, you must reference the assigned appeal case number and provide information on all correspondence submitted to the PRRB or the MAC or Federal Specialized Services (FSS).

Where to send PRRB hearing request

Provider’s request for a PRRB hearing should be sent to the Provider Reimbursement Review Board, First Coast Service Options, Inc. (First Coast) and Federal Specialized Services (FSS). Requests and/or correspondence sent to the PRRB and First Coast should be emailed if possible. The request should be addressed as follows:
Chairman, PRRB
CMS Office of Hearings
1508 Woodlawn Drive, Suite 100
Baltimore, MD 21207
Copies of the provider’s request should be sent to
PRRB Appeals
Federal Specialized Services
1701 S. Racine Avenue
Chicago, IL 60608-4058
Email contact: prrb@fssappeals.com
and
JN Provider Audit & Reimbursement
First Coast Service Options, Inc.
532 Riverside Avenue
Jacksonville, FL 32202-4914
Email contact: geoff.pike@fcso.com
For directions on what to include in your request, and for other information about the Board’s procedures, please consult the Board’s instructions external pdf file.
You may also obtain a copy by writing to the board at the above address or by telephoning the Board at 410-786-2671.
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.