Medicare Part B Administrative Law Judge (ALJ) Appeals
Note: Information on the Settlement Conference Facilitation Pilot for Part A appeals can be accessed by clicking here.
Settlement Conference Facilitation (SCF) is a pilot alternative dispute resolution process designed to bring the appellant and the Centers for Medicare & Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the third level of the Medicare claim appeals process. If a resolution is reached, a settlement document is drafted by the settlement conference facilitator to reflect the agreement. The document is signed by the appellant and CMS at the settlement conference session. As part of the agreement, the request(s) for an ALJ hearing for the claims covered by the settlement will be dismissed.
The settlement conference facilitator uses mediation principles to assist the appellant and CMS in working toward a mutually agreeable resolution. The facilitator does not make official determinations on the merits of the claims at issue and does not serve as a fact finder, but may help the appellant and CMS see the relative strengths and weaknesses of their positions. The settlement conference facilitator is an employee of the Office of Medicare Hearings and Appeals (OMHA), which is a component of the Health and Human Services Office of the Secretary, and is organizationally and functionally separate from CMS.
The first phase of this pilot began in June 2014. To date, Phase I of the pilot successfully settled over 2,000 Medicare Part B OMHA appeals. In Fall 2015, OMHA initiated Phase II of the pilot and expanded the program to include most Part B provider/supplier appeals where the request for ALJ hearing was filed prior to October 1, 2015.
All Medicare Part B providers and suppliers, who have OMHA appeals pending, are encouraged to read the materials on this website to familiarize themselves with the eligibility requirements and request process for settlement conference facilitation.
OMHA conducted an Open Door Teleconference on October 15, 2015, to answer questions from the appellant community related to OMHA’s SCF pilot. Participant-submitted questions and accompanying answers can be found in the Settlement Conference Facilitation Pilot Fact Sheet.
The OMHA SCF pilot is different and separate from the CMS Part A Hospital Appeals Settlement option for resolving Part A inpatient admission denials that was announced August 29, 2014 and concluded in September 2015. Information on the CMS program can be accessed by clicking here.
Phase II Appeal Eligibility
To be eligible for Phase II of the SCF pilot:
- A request for hearing must appeal a Medicare Part B Qualified Independent Contractor (QIC) reconsideration decision;
- The appellant must be a Medicare provider or supplier (for the purposes of this pilot, “appellant” is defined as a Medicare provider or supplier that has been assigned a National Provider Identifier (NPI) number (see the Settlement Conference Facilitation Pilot Fact Sheet for more information on this eligibility requirement));
- The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration;
- All jurisdictional requirements for a hearing before an ALJ must be met for the request for hearing on all appealed claims;
- The request for hearing must not be scheduled for an ALJ hearing;
- The request for hearing must have been filed by September 30, 2015;
- The amount of each individual claim must be $100,000 or less (for the purposes of an extrapolated statistical sample, the extrapolated amount must be $100,000 or less
- At least 20 claims must be at issue, or at least $10,000 must be in controversy if fewer than 20 claims are involved;
- There cannot be an outstanding request for OMHA statistical sampling for the same claims;
- The request must include all of the appellant’s pending appeals for the same item or service at issue that meet the SCF criteria. For example, if an appellant has 50 wheelchair appeals pending that meet the requirements above, the appellant must submit a request for SCF for all 50 wheelchair appeals.
- Appellants may not request SCF for some but not all of the items or services included in a single appeal. For example, if an individual appeal has at issue 10 diagnostic tests and 10 drugs/biologicals, an appellant may not request that the diagnostic tests go to SCF and the drugs/biologicals go to hearing.
- The appealed claim(s) must not involve services, drugs, or biologicals billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes (e.g., CPT Code 38999 Unlisted procedure, hemic or lymphatic system; J3490 Unclassified drugs);
- Equipment or items (excluding drugs or biologicals) which are billed under unlisted, unspecified, unclassified, or miscellaneous healthcare codes are eligible for SC
- The appellant has not filed for bankruptcy and/or does not expect to file for bankruptcy in the future; and
- The appellant has received an Office of Medicare Hearings and Appeals Settlement Conference Facilitation Preliminary Notification stating that the appellant may request SCF for the claims identified in the SCF spreadsheet. An appellant may not formally request a settlement conference until receiving this notice, but an appellant can initiate the process by filing its expression of interest (see Settlement Conference Facilitation Phase II Process below).
Requests for review of QIC dismissals are not eligible for the SCF process. Beneficiary-initiated appeals of QIC reconsiderations are not included in this pilot because those appeals are being prioritized for a hearing before an ALJ. Appeals arising from Medicare Part C, Medicare Part D, and appeals of Social Security Administration decisions regarding entitlement, Part B late enrollment penalties, and Part B and Part D income related monthly adjustment amounts (IRMAAs) are not eligible for the Settlement Conference Facilitation process at this time.
Phase II Process
The process for Phase II of the pilot has been refined to reduce the burden on appellants and more efficiently identify appeals that can be addressed in the SCF process. The process for SCF will proceed as follows:
- Appellants submit a Medicare Part B SCF Expression of Interest requesting that OMHA run a preliminary report of its pending OMHA appeals and initiate the SCF request process with its pending appeals. Alternatively, OMHA may initiate a preliminary report on its own initiative or at the request of CMS.
- If an appellant is interested in SCF for their Medicare Part A and Medicare Part B appeals, the appellant must submit a Medicare Part A SCF Expression of Interest with their Medicare Part B SCF Expression of Interest.
- OMHA will forward to CMS a preliminary report of the appellant’s pending OMHA appeals. CMS then has 15 calendar days to determine whether it will participate with the appellant(s) identified on the preliminary report.
- Please note: Any party may decline to participate at any time during the settlement conference process. Pilot participation is not mandatory for any party.
- After CMS responds to the preliminary report and indicates it will participate, OMHA will complete an SCF Spreadsheet for the appellant(s) listed on the preliminary report. The spreadsheet will contain all OMHA appeals eligible for the pilot.
- OMHA will send an SCF Preliminary Notification and SCF Spreadsheet to the appellant(s) on a compact disc.
- The appellant will have 15 calendar days from receipt of the SCF Preliminary Notification to file a complete SCF Request package. It is presumed that the appellant receives the preliminary notification and spreadsheet within 5 calendar days after the date printed on the SCF Preliminary Notification.
- The appellant’s request package must include the following information and/or materials:
- Request for SCF form;
- SCF Agreement of Participation form; and
- SCF Request Spreadsheet (with all appellant columns completed).
The appellant must submit all of these documents electronically on a flash drive or a compact disc.
- After OMHA receives the appellant’s complete SCF request package, OMHA will issue a confirmation notice to the appellant and CMS. The confirmation notice will include all of the appeals that will be subject to a settlement agreement if one is reached.
- A pre-settlement conference call with the appellant, CMS, and the OMHA facilitators will be scheduled approximately four weeks after issuance of the confirmation notice.
- A settlement conference will be scheduled approximately three to four weeks after the pre-settlement conference call is completed.
- The settlement conference between the appellant and CMS will be conducted.
- If a settlement agreement is reached, the appellant’s requests for ALJ hearing for the claims at issue will be dismissed.
- If a settlement agreement is not reached, the appeals will return to the adjudication process in the order the request for hearing was received (for example, if you filed your request for hearing in October 2014, the request will be processed with other requests for hearing received in October 2014). If an appeal was already assigned to an OMHA adjudicator, the appeal will return to the adjudicator’s docket.
We encourage you to read the entire Settlement Conference Facilitation Pilot Fact Sheet and process flowchart linked in the Downloads section to understand how this pilot will proceed. Please continue to visit this site for the most up-to-date instructions.
Requesting Settlement Conference Facilitation
Appellants are encouraged to follow all directions on the request package forms linked on this website. Appellants must not alter forms or spreadsheets to suit their own needs.
Failure to follow the directions set out in the SCF Preliminary Notification or the attached forms may result in rejection of your request for settlement conference.
Rejection of a request for SCF is not appealable. Prior to requesting SCF, please read the Settlement Conference Facilitation Pilot Fact Sheet, Settlement Conference Process Flowchart, Request for Settlement Conference Facilitation Form, Settlement Conference Facilitation Request Spreadsheet, Settlement Conference Facilitation Agreement of Participation, and the Settlement Conference Facilitation Settlement Agreement Template. This will ensure you understand the requirements and procedures of the pilot program and your responsibility as a potential participant in the process.
Open Door Teleconference
OMHA conducted an Open Door Teleconference on October 15, 2015 to answer questions from the appellant community related to OMHA’s Settlement Conference Facilitation Pilot. Participant submitted questions and accompanying answers can be found in the Settlement Conference Facilitation Pilot Fact Sheet linked in the Downloads section below.
If you have any questions regarding the Settlement Conference Facilitation pilot, you can submit your questions via email to OMHA.SCF@hhs.gov.
- Settlement Conference Facilitation Pilot Fact Sheet
- Settlement Conference Facilitation Process Flowchart
- Settlement Conference Facilitation Expression of Interest (Part B Appeals)
- Request for Settlement Conference Facilitation Form
- Settlement Conference Facilitation Agreement of Participation
- Addendum to Settlement Conference Facilitation Agreement to Participate
- Settlement Conference Facilitation Request Spreadsheet
- Settlement Conference Facilitation Settlement Agreement Template