PRRB Amends its Rules and Requires More Thorough Documentation

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Explore:  Appeals Documentation PRRB

On March 1, 2013, the Provider Reimbursement Review Board (PRRB) amended its rules for the first time since July 1, 2009.  The changes are effective immediately and will “apply to appeals pending as of, or filed on or after, March 1, 2013.”  The new rules, which are available here with the new or revised text highlighted, have prompted changes to many of the Board’s Model Forms as well.  Many of the rule changes focus on providing additional documentation to help the Board establish that it has jurisdiction over each issue under appeal.  The Board issued Alert 9 announcing the rule changes and providing a helpful, though non-exhaustive, summary of the changes. 

The summary of the changes from Alert 9 are reproduced below with our comments added in brackets. 

Rule 3.3 now requires all Board correspondence be served on the opposing party AND the appeals support contractor.  [This has long been considered “best practice,” but is now required by the Board’s rules.]

Rule 5.1 includes a reminder that it is the Representative’s responsibility to keep all contact information up to date with the Board, including the current email address, as correspondence is frequently issued by the Board electronically.  [As the Board has moved toward electronic communication, including sending the critical due dates letter by email, keeping one’s email address current has become essential.] 

Rule 7.1 requires that when appealing a Revised NPR, additional documentation is now required to support that the issue under appeal was revised in the Revised NPR pursuant to 42 C.F.R 405.1889.  [In addition to including the Revised NPR (RNPR) itself, the Board now wants a copy of the preceding NPR, any reopening request or reopening notice associated with the RNPR, the RNPR workpapers, and any applicable cost report worksheets.  The point of these documents is to definitively prove that the contractor revised the issue being appealed from the RNPR in the RNPR itself.]

Rule 16 adds additional documentation requirements when filing a Form D to transfer an issue from an individual appeal to a group appeal as well as when filing a Form E to file directly from a Final Determination into a group appeal.  [A provider must now provide documentation proving that the issue it is requesting to have transferred from its individual appeal to a group appeal is currently part of its individual appeal.]

Rule 20.1 requires Schedules of providers with supporting documentation to be sent simultaneously to the Lead Intermediary and the Board.  [Previously, the Board only received the cover schedule, without the supporting documentation.  A cover schedule, by itself, may still be sent to the appeals support contractor.]

Rule 21 has been significantly revised to include additional informational requirements on the Schedule of Providers (Schedule G) and additional supporting documentation requirements.  [The changes to the schedule of providers are somewhat significant and many of them require additional documentation to establish the complete jurisdictional history of an issue.  For example, all transfers of an issue must now be documented.  Rule 21 should be separately reviewed by anyone filing a schedule of providers.  Notably, the rule now states that “if the appeal was filed after August 21, 2008, include a copy of the proof of delivery . . . .”  In addition, if the appeal item was self-disallowed, “a provider must submit evidence of protest” for “cost reporting periods that end on or after December 31, 2008.”]

Rule 27.6 requires the additional five copies of final position papers to be submitted to the Board seven to ten business days prior to a Board hearing.

Many of the changes in the Board’s amended rules were already considered “best practices” under the old rules.  Now that they are required, however, failure to comply with them may be grounds for the dismissal of an appeal. 

Reporter, Daniel J. Hettich, Washington, D.C., +1 202 626 9128, dhettich@kslaw.com.

Topics:  Appeals, Documentation, PRRB

Published In: Health Updates

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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