CMS Issues Guidance on Appeals for EHR Incentive Program Determinations


The CMS Office of Clinical Standards and Quality (OCSQ) issued guidance last week outlining the procedures for appealing determinations made under the Medicare Electronic Health Record (EHR) Incentive Program. The guidance establishes a two-level appeals process—an informal review and a reconsideration—for both eligible hospitals and eligible professionals (EPs) to challenge (i) eligibility determinations, (ii) meaningful use determinations, and (iii) incentive payment calculations.

More specifically, these appeal categories consist of the following:

1. An eligibility appeal allows a provider to show that all the EHR incentive program requirements were met and that the provider should have received a payment but could not because of circumstances outside of the provider’s control.

2. A meaningful use appeal allows a provider to show that the provider is using certified EHR technology and met the meaningful use objectives and associated measures after a successful attestation.

3. An incentive payment calculation appeal allows an EP to show that he or she provided claims data for inclusion that was not used in determining the amount of the incentive payment. (Only EPs are permitted to use the process to appeal incentive payment calculations. CMS's guidance states that it will develop procedures to permit eligible hospitals and CAHs to appeal these disputes to the Provider Reimbursement Review Board.)

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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