Process Improvement

4.5-Process Improvement Where appropriate and feasible, the parties will provide recommendations on process refinements. Such changes will be presented and approved through the process described in Section 2.5 regarding changes to the JOA. Appendix A. Master Contact List Table A-1. Supplemental Medical Review Contractor POC Role Representative Contact Number E-mail JOA POC Project Manager MR Director Information Security Manager MR Manager Operations Manager Liaison, Hearing & Appeals Coordinator Table A-2. Unified Program Integrity Contractor xx POC Role Representative Contact Number E-mail UPIC JOA POC UPIC Operations POC UPIC Appeals Manager UPIC Appeals Manager UPIC Overpayment team leader—Audit UPIC Overpayment team Leader—Recoupment UPIC POE Manager JOA Signatory JOA Signatory Table A-3. Centers for Medicare & Medicaid Services SMRC COR SMRC ACOR/BFL Contracting Officer Contracting Specialist Appendix B. JOA Approval Signature Form Company/Entity Name: Signatory Name (Printed): Signatory Signature: ______________________________________________ Date: ____/____/____ Company/Entity Name: Signatory Name (Printed): Signatory Signature: ______________________________________________ Date: ____/____/____ Company/Entity Name: Signatory Name (Printed): Signatory Signature: ______________________________________________ Date: ____/____/____ Exhibit 45 – UPIC Prepayment and Postpayment Notification Letter (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) DATE: UPIC NAME/JURISDICTION: PROVIDER NAME: UPIC CONTACT/PHONE NUMBER: PROVIDER ADDRESS: UPIC ADDRESS: PROVIER NUMBER: Dear Provider Name: As a Medicare contractor, the Unified Program Integrity Contractor (UPIC) is required by the Centers for Medicare & Medicaid Services (CMS) to analyze claims payment data in order to identify areas with the greatest risk of inappropriate program payment. Specifically, as a (indicate UPIC), (write UPIC Name) is required to investigate situations of potential fraud, waste, and abuse. Your claims have been selected for a comprehensive medical review of your billing for Medicare services pursuant to CMS’ statutory and regulatory authority. You were selected for this review because our analysis of your billing data indicates that there may be aberrancies in your billing. We have selected claims for services provided during the period through . You will subsequently receive a request for medical records, which will explain the specific documentation that is being requested. If you have any questions regarding the letter requesting medical records/documentation, please contact (UPIC Contact’s Name) at (Phone Number of UPIC Contact). Thank you for your prompt response to the request for medical records/documentation. Exhibit 46.1 - MAC Unified Postpayment ADR Sample Letter (Rev.557, Issued: 11-26-14, Effective: 12-29-14, Implementation: 12-29-14) Date: Reference ID: Attention: Address: NPI: PTAN: Phone: Fax: Request Type & Purpose: Notification of Post-payment Probe Review and Request for Medical Records Subject: Additional Documentation Required Dear Medicare Provider/Supplier, The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper payment of Medicare claims3. As part of our effort to accomplish this goal, the Medicare Administrative Contractor (MAC) program will conduct a post-payment medical review of selected Medicare Part A claims. Reason for Selection As an A/B MAC, 'Review Contractor Name' is tasked with preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. 'Review Contractor Name' recently completed review of a sample of service-specific claims for HIPPS code XXXXX (1st or 2nd episode with 11 to 13 therapy visits). The calculated charge denial rate (CDR) for these claims was 100%. Refer to the enclosed Encrypted CD for the complete list of claims and denial reasons. Action: Additional Documentation Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providers/suppliers are required to send supporting medical records to the MAC program. Providing medical records of Medicare patients to the MAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. Case ID: 1212121 Patient Name Date of Birth HIC Number Date of Service Rendering Provider / Supplier Claim ID Procedure Code When: mm/dd/yyyy Please provide the requested documentation by mm/dd/yyyy. A response is still required by mm/dd/yyyy even if you are unable to locate the requested information. When the review is completed, you will be notified of the results. The CMS’ goal is to complete the review and deliver the results to providers/suppliers within 60 days of the receipt of all medical records needed for the review. 3 Social Security Act Sections 1833(e), 1815(a), and 1842(p)(4) Consequences If the provider/supplier fails to send the requested documentation or contact CMS by mm/dd/yyyy, the provider’s/supplier’s Medicare contractor will initiate claims adjustments or overpayment recoupment actions for these undocumented services. Instructions The documentation submitted for this review must be a copy of the patient’s medical record for each encounter clearly identified for each requested beneficiary and the date of service. Providers/suppliers are responsible for obtaining supporting documentation from third parties (hospitals, nursing homes, suppliers, etc.). • Refer to the ‘Supporting Documentation’ attachment for a list of required supporting documentation to be submitted. • Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to CMS or the MAC program. • The CMS encourages providers/suppliers to respond quickly. • Please do not include Powers of Attorney, Living Wills, or Correspondence. • During this review period and at all times, in order to receive payment, providers/suppliers must continue to submit claims for all services performed on a beneficiary. Submission Methods Providers/Suppliers may submit this documentation in any of the following ways: Via postal mail or Encrypted CD/DVD: 1. Include a copy of the Post Pay request letter with your documents. 2. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set of documents to be submitted. a. An image of the coversheet may be included with the CD/DVD or may be scanned as the first image seen within your CD/DVD. 3. When submitting responses for multiple claims, please make a copy of the enclosed Part A Post Pay ADR Response Separator Sheet and insert between the responses for each Document Control Number (DCN). 4. If the CD/DVD is password protected, send an email to John.Doe@Company.com and Jane.Doe@Company.com and include the package tracking number and password. 5. Mail to the following: Regular Mail: Overnight Mail: Company Name Company Name Medical Review Medical Review Mail Code XXXX OR Mail Code XXXX Post Office Box XXXXX Street Address City, State Zip Code City, State Zip Code Via fax to: 1. XXX-XXX-XXXX 2. Include a copy of the ADR letter with your documents. 3. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set of documents to be faxed. 4. When submitting Post Pay ADR responses with multiple claims, make a copy of the enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each Document Control Number (DCN). Via Electronic Submission of Medical Documentation (esMD): 1. Include a copy of the Post Pay request letter with your documents. 2. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set of documents to be sent. 3. When submitting Post Pay ADR responses with multiple claims, make a copy of the enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each Document Control Number (DCN). 4. Convert all documents, including your cover sheets, to PDF. 5. Submit your documentation to your CONNECT-compatible gateway or HIH. 6. More information on esMD can be found at www.cms.gov/esMD Questions If you have any questions please contact XXXXXXXX at XXX-XXX-XXXX or via postal mail at the following: Company Name Street Address City, State Zip Code Sincerely, A/B MAC Jurisdiction X Medical Review Attachments / Supplementary Information 1. Encrypted CD with a listing of claims requiring medical documentation 2. Supporting Documentation Required List 3. ADR Response Cover Sheet Form 4. Separator Sheet Form Exhibit 46.2 - DME MAC Unified Post-Payment ADR Sample Letter (Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) Letter Date: Provider/Supplier Name Provider/Supplier Address City, State Zip Case ID #: NPI /Provider #: PTAN: Request Type & Purpose: New Request, Post-Payment Claim Review Subject: Additional Documentation Required Dear Medicare Provider/Supplier, The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper payment of Medicare claims1. As part of our effort to accomplish this goal, the Medicare Administrative Contractor (MAC) program will conduct a post-payment medical review of selected Medicare DME claims. Reason for Selection In the xx quarter 20XX, “Supplier’s Name” HCPCS code XXXXX claim volume was two or more standard deviations above the norm when compared to all suppliers billing HCPCS code XXXXX in Jurisdiction X. This high claim volume billed by a new supplier for a high dollar item is of concern to the DME MAC. When services appear outside the norm, the DME MAC must verify whether the potential error(s) represent an unacceptable practice. The DME MAC is validating this concern by performing a post-payment review on ## randomly selected claims billed by “Supplier’s Name”. ACTION: MEDICAL RECORDS REQUIRED Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. The Centers for Medicare & Medicaid Services DME MAC program has randomly selected one or more of your Medicare claims for review, and providers/suppliers are required to send supporting medical records when requested. Providing medical records of Medicare patients to the MAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. Please refer to the Instructions Section below for a list of supporting documentation required. 1Social Security Act Sections 1833 [42 USC 1320c-5 (a) (3)] Case ID: XXXXXXX Patient Name MBI Date of Service Claim ID Procedure Code When: MM/DD/YYYY Please provide the requested documentation by mm/dd/yyyy. A response is still required by mm/dd/yyyy even if you are unable to locate the requested information. Consequences If the provider/supplier fails to send the requested documentation or contact CMS by mm/dd/yyyy, the provider’s/supplier’s Medicare contractor will initiate claims adjustments or overpayment recoupment actions for these undocumented services. Instructions • Submit supporting documentation from third parties (hospitals, nursing homes, suppliers etc.). Providers/suppliers are responsible for obtaining and providing the following documentation: o Physician’s notes within 30 days of initial date: mm/dd/yyyy o Diagnostic Tests • Submit the bar coded cover sheet with your submission (optional) • Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to CMS. Submission Methods Providers/suppliers may submit this documentation in any of the following ways: • Via postal mail to: Company Name Company Address City, State Zip Code • Via fax to: XXX-XXX-XXXX • Via Electronic Submission of Medical Documentation (esMD): - More information on esMD can be found at www.cms.gov/esMD - When sending records via esMD, please include a CASE ID number in your file transmission • Via Encrypted CD: See attachment for detailed instructions. Questions If you have any questions, please contact: Contact Name Department Company Name Contact Address City, State Zip Code Office: XXX-XXX-XXXX Toll Free: XXX-XXX- XXXX Fax: XXX-XXX- XXXX Company Email Address Company Website Sincerely, DME MAC Jurisdiction X Medical Review Attachments / Supplementary Information 1. Important Notices 2. Cover Sheet 3. Change of address information 4. Appeals process 5. Comparative Data 6. Encrypted CD Submission Process Exhibit 46.3 – Recovery Audit Contractor (RAC) Unified Postpayment ADR Sample Letter (Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) Region X RAC Date: Reference ID: Attention: Address: NPI: PTAN: Phone: Fax: Request Type & Purpose: Additional Documentation Required and Request for Medical Records Dear Medicare Provider/Supplier, The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce the improper payment of Medicare claims8 The Recovery Audit Program, mandated by Congress has been developed to assist in accomplishing this goal. Reason for Selection: Your RAC, (insert name of RAC), is requesting additional documentation for the selected list of claims as part of a post-payment complex review approved by CMS. Providers/suppliers will receive a Review Results Letter after a claim determination has been made. If an improper payment (underpayment or overpayment) is identified, these claims will be sent to your Medicare Administrative Contractor (MAC) for adjustment. Please refer to the enclosed Claims Selected for Review Spreadsheet for a list of selected claims. Action: Additional Documentation Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providers/suppliers are required to send supporting medical records to (insert RAC name). Providing medical records of Medicare Recovery Auditor logo patients to (insert RAC name) does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. When: mm/dd/yyyy Please provide the requested documentation by mm/dd/yyyy. A response is still required by mm/dd/yyyy even if you are unable to locate the requested information. When the review is complete, you will be notified of the results. (Insert RAC name)’s goal is to complete the review and deliver the results to providers/suppliers within 30 days of receipt of all medical records needed for the review. Consequences If the provider/supplier fails to send the requested documentation to (insert RAC’s name) by mm/dd/yyyy, the provider’s/supplier’s MAC will initiate claims adjustments or overpayment recoupment actions for these undocumented services. Instructions 1. The documentation submitted for this review must be a copy. Do not submit original documentation. 2. A copy of this additional documentation request letter should be affixed to the documentation. Please bundle documents for each claim separately to enable us to ensure receipt of all requested documents. 3. Providers/suppliers are responsible for obtaining supporting documentation from third parties (hospitals, nursing homes, suppliers, etc.). 4. Refer to the ‘Supporting Documentation’ attachment for a list of required supporting documentation to be submitted. 5. The RAC is required to reimburse providers for the submission of medical records for the following claim types: Acute Care Inpatient Prospective Payment System Hospital Claims, Long Term Care Hospital Claims, non-PPS institution, and practitioners. 6. If you meet the Medicare definition of one of these provider types, you will be reimbursed for the cost of providing copies of the additional documentation. Payment will be issued to you within 45 days of receiving the additional documentation. 7. For PPS Providers, payment will be in the amount of $0.12 per page, plus the cost of First Class postage, if mailed via USPS. For non-PPS Providers and practitioners, payment will be in the amount of $0.15 per page, plus the cost of First Class postage, if mailed via USPS. The amount per page, for the respective providers, will not exceed this quantity, and the maximum payment per medical record, submitted via mail, fax, CD/DVD shall not exceed $25.00. For medical records submitted electronically (via esMD), the “per page” amount will be the same as those previously noted. However, the maximum payment per medical record shall not exceed $27.00, including a $2.00 transaction fee. 8. Please do not include Powers of Attorney, Living Wills, Correspondence, or Prior Episodes of Care. 9. Requirements for submitting imaged documentation on CD or DVD can be found at (insert RAC web address) or by calling the RAC’s Call Center at XXX-XXX-XXXX. Submission Methods Providers/suppliers may submit this documentation in any of the following ways: Via postal mail or Encrypted CD/DVD: 1. Include a copy of the ADR letter with your documents. 2. Mail to the following: Regular Mail: Company Name Medical Review Mail Code OR Post Office Box City, State Zip Overnight Mail: Company Name Medical Review Mail Code Address City, State Zip Via fax to: 1. XXX-XXX-XXXX 2. Include a copy of the ADR letter with your documents. Via Electronic Submission of Medical Documentation (esMD): 1. Include a copy of the ADR letter with your documents. 2. Submit your documentation to your CONNECT-compatible gateway or HIH. 3. More information on esMD can be found at www.cms.gov/esMD Questions If you have any questions please contact: Recovery Auditor Audit Contractor Customer Service General Inquiry XXX-XXX-XXXX Address City, State Zip Sincerely, RAC Region X Attachments / Supplementary Information 1. Claims Selected for Review Spreadsheet Exhibit 46.4 – CERT Unified Post-payment ADR Sample Letter (Rev. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26) Provider Name Address 1 Address 2 City ST 00000 Date: Reference ID: CID# NPI/ Provider #: Phone: Fax: Request Type & Purpose: New Request, Post-Payment Claim Review Subject: Additional Documentation Required Dear Medicare Provider/Supplier, The Centers for Medicare & Medicaid Services (CMS), through the Comprehensive Error Rate Testing (CERT) program, carries out the task of requesting, receiving, and reviewing medical records4. The CERT program reviews selected Medicare A, B and DME claims and produces annual improper payment rates. For more information regarding the CERT program, please visit www.cms.gov/CERT. Reason for Selection The CMS’ CERT program has randomly selected one or more of your Medicare claims for review. Action: Medical Records Required Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providers/suppliers are required to send supporting medical records to the CERT program. Providing medical records of Medicare patients to the CERT program does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. Providers/suppliers are responsible for obtaining and providing the documentation as identified on the attached Cover Sheet. The CMS is not authorized to reimburse providers/suppliers for the cost of medical record duplication or mailing. If you use a photocopy service, please ensure that the service does not invoice the CERT program. 4 Social Security Act Sections 1833 [42 USC §1395l(e)] and 1815 [42 USC §1395g(a)]; 42 CFR 405.980-986 When: mm/dd/yyyy Please provide the requested documentation by mm/dd/yyyy. A response is still required by mm/dd/yyyy even if you are unable to locate the requested information. Consequences If the provider/supplier fails to send the requested documentation or contact CMS by mm/dd/yyyy, the billing provider’s/supplier’s Medicare contractor will initiate claims adjustments or overpayment recoupment actions for these undocumented services. Instructions • Specific information and instructions pertaining to the sampled claim and returning requested documents are shown on the following pages of this letter. • Please include the cover sheet with your submission Submission Methods You may submit this documentation in any of the following ways: • Via postal mail to: CERT Documentation Center 8701 Park Central Drive, Suite 400-A Richmond, VA 23227 • Via Fax: 804-261-8100 1. Use the coversheet as the only coversheet. 2. Do not add your own coversheet—this slows down the receipt and identification process 3. Send a separate fax transmission for each individual claim. • Via Electronic Submission of Medical Documentation (esMD): 1. Include a CID# or Claim number and the cover sheet in your file transmission. 2. Information on esMD can be found at www.cms.gov/esMD. 3. For questions about esMD please contact: esMDBusinessOwners@cms.hhs.gov. • Via CD: 1. The images should be encrypted per HIPAA security rules. 2. If encrypted, the password and CID# must be provided via email to CERTMail@empower.ai or via fax to 804-261-8100. 3. Must contain only images in TIFF or PDF format • Via Email Attachment to CERTMail@empower.ai: 1. The email attachment(s) should be encrypted per HIPAA security rules. 2. If encrypted, the password and CID# must be provided via phone to 888-779-7477 or via fax to 804-261-8100. 3. Must contain only attachments in TIFF or PDF format. Questions If you have any questions, please contact: CERT Documentation Center 8701 Park Central Drive, Suite 400-A Richmond, VA 23227 Email questions to: CERTProvider@empower.ai Toll Free: 888-779-7477 Fax: 804-261-8100 Sincerely, Contact Name Director, Payment Accuracy & Reporting Group Office of Financial Management Centers for Medicare & Medicaid Services Attachments / Supplementary Information 1. Claim Information 2. Bar Coded Cover Sheet Exhibit 46.5 – SMRC Unified Postpayment ADR Sample Letter (Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) Letter Date: Provider/Supplier Name Provider/Supplier Address City, State Zip Project ID Number: NPI/PROVIDER #: PTAN: Request Type & Purpose: Notification of Post-Payment Claim Review Subject: Additional Documentation Required Dear Medicare Provider/Supplier, The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper payment of Medicare claims.10 As part of our effort to accomplish this goal, CMS has retained “Contractor Name” as the Supplemental Medical Review Contractor (SMRC) to conduct a medical record review of selected Part A and Part B claims. Additional information regarding this contract can be found at: ‘website URL’. Reason for Selection Reason for Project for XXXX code(s): • Service on Review - Short Description This constitutes new and material evidence that establishes good cause for reopening the claim. Providing additional documentation for each claim is authorized by CMS and is being requested. Action: Medical Records Required Federal law 10 requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providing medical records of Medicare patients to the SMRC does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. When: mm/dd/yyyy Please provide the requested documentation by mm/dd/yyyy. A response is still required by mm/dd/yyyy even if you are unable to locate the requested information. Please note, you may request an extension to submit the requested documentation, if your request is made by mm/dd/yyyy. 10 Social Security Act Sections [42 USC 1320c-5(a) (3)], 1833 [42 USC 13951 (e)], and 42 CFR 405.980(b) When the review is completed, you will receive a review results letter after a determination has been made. The results letter will stipulate if any underpayment(s) or overpayment(s) were identified. Consequences If you or your facility fail to send the requested documentation or request an extension by mm/dd/yyyy, the “Contractor Name” will initiate claims adjustments or overpayment recoupment actions with your Medicare Administrative Contractor for these undocumented services. Instructions • This agency does not reimburse providers/suppliers for the cost associated with copying of medical records from any setting. When records are requested, the expense of supplying medical records is a part of the administrative costs of doing business with Medicare. Therefore, invoices from record retention centers and copying agencies are not eligible for reimbursement. • Refer to the ADR Claim List for selected claims. • A copy of this request letter should be affixed to the documentation submitted. • All documentation should be submitted within 45 days of the date of this notice. • Please refer to the Submission Methods section below for additional information on document preparation and available submission methods. • Refer to the enclosed SMRC Response Cover Sheet Form(s) for documentation requirements. • Note: - Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a legible handwritten or electronic signature. - Stamp signatures are not acceptable. Beneficiary identification, date of service, and provider of the service(s) should be clearly identified on the submitted documentation. Documentation submitted in response to this request shall comply with these requirements. - This may require providers/suppliers to contact the hospital or other facility where services were provided to obtain signed progress notes, plan of care, discharge summary, etc. - If signature requirements are not met, the reviewer will conduct the medical review without considering the documentation with the missing or illegible signature. This could lead the reviewer to determine that medical necessity for the service(s) billed has not been substantiated. - “Contractor name” recommends that providers review their documentation prior to submission and ensure that all medical record entries and orders are signed appropriately. For documentation with a missing, illegible or electronic signature, a signature log or signature attestation may be submitted additionally as part of the ADR response. For detailed guidance regarding Medicare signature requirements, refer to the Medicare Program Integrity Manual, Publication 100-08, Chapter 3 and Section 3.3.2.4. Submission Methods Providers/suppliers may submit the documentation in any of the following ways: • Include a copy of the Post Pay request letter with your documents. • Complete the SMRC Response Cover Sheet Form (enclosed) for each claim number requested and place on top of each set of documents to be submitted. • When submitting Post Pay ADR responses with multiple claims, make a copy of the enclosed SMRC Response Cover Sheet Forms and send each set of documents separately for each claim number. • Via fax to: XXX-XXX-XXXX • Via Electronic Submission of Medical Documentation (esMD): − Convert all documents, including your cover sheets, to PDF. − Submit your documentation to your CONNECT-compatible gateway or HIH. − More information on esMD can be found at www.cms.gov/esMD • Via postal mail or Encrypted CD/DVD − Image(s)s must be submitted in PDF or multi-page TIF format. − If the CD/DVD is password protected, send an email to “Email Address”. Include the Project Number from this letter, the package tracking number and password. Contractor Name and Mailing Address: Questions Thank you for your participation with this review. If you have any questions, please contact: Office: XXX-XXX-XXXX Sincerely, Supplemental Medical Review Contractor Program Manager Attachments / Supplementary Information 1. SMRC Point of Contact Information 2. SMRC ADR Claim List 3. SMRC Response Cover Sheet Form(s) Exhibit 47 – Program Integrity Unit Contacts within the State Medicaid Agency (Rev. 13000; Issued: 12-12-24; Effective: 12-10-24; Implementation: 12-10-24) State POC Phon e POC E-mail Address Alabama Beverly Churchwell (334) 242- 5318 Beverly.Churchwell@medicaid.alabama.go v Alaska Doug Jones (907) 269- 0361 doug.jones@alaska.gov American Samoa Matilda Kruse (684) 699- 4777 matilda.kruse@medicaid.as.gov Arizona Vanessa Templeman (602) 877- 9066 Vanessa.Templeman@azahcccs.gov Arkansas Heather Callaway (501) 687- 8349 Heather.callaway@arkansas.gov California Bruce Lim (916) 440- 7552 bruce.lim@dhcs.ca.gov Colorado Bart Armstrong (303) 866- 4940 Bart.Armstrong@hcpf.state.co.us Connecticut John Jakubowski (860) 424- 5855 John.Jakubowski@ct.gov Delaware Joe Riley (acting) (302) 255- 9647 Joe.Riley@delaware.gov District of Columbia Kevin O’Donnell (202) 299- 5619 Kevin.Odonnell2@dc.gov Florida Kelly Bennett (850) 412- 4600 Kelly.Bennet@ahca.myflorida.com Georgia Johnny Brooks (404) 463- 7144 johnny.brooks@dch.ga.gov Guam Jeffrey San Nicolas (671) 735- 7475 Jeffrey.Sannicolas@dphss.guam.gov State POC Phon e POC E-mail Address Hawaii Shelley Siegman (808) 692- 7962 SSiegman@dhs.hawaii.gov Idaho Lori Stiles (208) 334- 0653 stilesl@dhw.idaho.gov Illinois Brian Dunn (312) 833- 5835 Brian.J.Dunn@illinois.gov Indiana Ben Ford (317) 234- 7711 Benjamin.Ford@fssa.in.gov Iowa Kimberly Pierson (515) 321- 8409 kpierso@dhs.state.ia.us Kansas Kansas Department of Health and Environmen t (785) 296- 1500 HCFProgramIntegrity@ks.gov Kentucky Jennifer Dudinskie (502) 564- 5472 Jennifer.Dudinskie@ky.gov Louisiana Angie Bihm (225) 342- 9287 Angela.Bihm@LA.gov Maine Valerie Hooper (207) 287- 4660 Valerie.Hooper@Maine.gov Maryland Mary Blackwell (410) 767- 4332 Mary.Blackwell@Maryland.gov Massachusett s Joan Senatore (617) 847- 3122 Joan.Senatore@state.ma.us Michigan Michelle Popowich (517) 284- 6966 Popowichm@michigan.gov Minnesota Amanda Novak Kathryn King- Scribbins (651) 431- 6378 (651) 431- 6956 Amanda.novak@state.mn.us kathryn.king-scribbins@state.mn.us State POC Phon e POC E-mail Address Mississippi Richard Cameron (601) 576- 4134 Richard.Cameron@medicaid.ms.gov Missouri VACANT Montana Heather Smith (406) 444- 4120 HeatherSmith@mt.gov Nebraska Anne Harvey (402) 471- 1718 anne.harvey@nebraska.gov Nevada Cynthia Leech (775) 684- 7964 Cleech@dhcfp.nv.gov New Hampshire Karen Carleton, RN Francesca Hennessy (603) 271- 8029 (603) 271- 5134 Karen.Carleton@dhhs.nh.gov Francesca.Hennessy@dhhs.nh.gov New Jersey Joshua Lichtblau Don Catinello Nina Galletto (609) 292- 4368 (609) 789- 5014 (609) 789- 5031 Joshua.Lichtblau@osc.nj.gov Don.Catinello@osc.nj.gov Nina.Galletto@osc.nj.gov New Mexico Lisa V. Medina- Lujan (505) 827- 7310 Lisa.Medina-Lujan@hsd.nm.us New York Frank T. Walsh, JR (514) 473- 8782 Frank.Walsh@omig.ny.gov North Carolina John E. Thompson (919) 527- 7701 John.E.Thompson@dhhs.nc.gov North Dakota Denise Martino (701) 328- 4024 Dmmartino@nd.gov Northern Mariana Islands Annie Rose Z. Reyes (670) 664- 4883 annierosezandueta@cnmimedicaid.com State POC Phon e POC E-mail Address Ohio Jeffrey Corzine (614) 387- 8369 Jeffrey.corzine@medicaid.ohio.gov Oklahoma Julie Dowell (405) 522- 7421 Julie.Dowell@okhca.org Oregon Fritz Jenkins Tamara McNatt (503) 358- 5246 Fritz.Jenkins@odhsoha.oregon.gov Tamara.McNatt@dhsoha.state.or.us Pennsylvania Karen Fickes (717) 705- 6858 kfickes@pa.gov Puerto Rico Maria D. Garcia- Ducos (787) 765- 2929 Ext. 6756 maria.garcia.ducos@salud.pr.gov Rhode Island Christopher Smith (401) 463- 0163 Christopher.smith@ohhs.ri.gov South Carolina Michael Targia (803) 898- 2608 Michael.Targia@scdhhs.gov South Dakota Stacy Bruels (605) 773- 3745 Stacy.Bruels@state.sd.gov Tennessee Floyd Price (615) 507- 6686 Floyd.N.Price@tn.gov Texas Steve Johnson (512) 415- 7980 Steve.Johnson@hhs.texas.gov Utah Gene Cottrell (801) 599- 4372 GCottrell@utah.gov Vermont Nadeth Fitzgerald (802) 760- 9432 Nadeth.Fitzgerald@vermont.gov State POC Phon e POC E-mail Address Virgin Islands Kevin Dennin (340) 774- 0930 Ext. 4478 Kevin.Dennin@dhs.vi.gov Virginia Tracy Sargent (804) 371- 2648 Tracy.Westerman@dmas.virginia.gov Washington Michael Brown (360) 725- 0913 Michael.brown@hcs.wa.gov West Virginia Andrew Pack (304) 352- 4253 Andrew.C.Pack@wv.gov Wisconsin Anthony Baize (608) 266- 2521 Anthony.Baize@dhs.winsconsin.gov Wyoming Andrew Chapin Susan Malm Portia Peterson (307) 777- 2504 (307) 777- 5609 (307) 777- 8985 Andrew.Chapin@wyo.gov Susan.Malm@wyo.gov Portia.Pterson1@wyo.gov Step 3- Did the provider render a medically necessary service Severity of Signs and Symptoms, and Step 2- Did the Patient Need Hospital Care? Exhibit 48 - Guideline for Hospital Patient Status Reviews (Rev. 13409; Issued: 09-12-25; Effective: 10-13-25; Implementation: 10-13-25) Note- If any of the following unforeseen circumstances resulted in a shorter stay, the stay is payable under Part A: • Death, • Transfer, • Departures Against Medical Advice (AMA), • Clinical Improvement, • Election of Hospice No Claim is NOT Payable under Part A Claim is NOT Payable under Part A * Reviewers shall consider complex medical factors that support a reasonable expectation of the needed duration of the stay relative to the 2-midnight benchmark. Both the decision to keep the beneficiary at the hospital and the expectation of needed duration of the stay are based on such complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered. Legal Disclaimer: This educational product was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational product may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. Exhibit 49 – Exhibit 49 – OMHA e-Appeal Portal (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) The OMHA e-Appeal Portal is a secure, web-based system that allows parties to electronically manage Medicare appeals before OMHA, including submitting case information and documents online instead of relying on paper and mail. The following exhibits are designed to help users effectively utilize this system: one provides step-by- step instructions for creating and accessing a portal account, and the other explains how to upload appeal documents within the portal so that information is properly associated with the correct case. Exhibit 49.1 – OMHA e-Appeal Portal - How to Access the Portal (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) The OMHA e-Appeal Portal is available at <hhs-ecape-portal.entellitrak.com>. Portal Account Creation: To create a new portal account, navigate to the website at <hhs-ecape- portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.” You will be redirected to ID.me and prompted to sign in or create an ID.me account. The portal utilizes ID.me to provide identity verification for new accounts and multi- factor authentication for secure sign-in to existing accounts. Creating an ID.me account requires a picture ID (such as a driver's license or passport) and an email address or phone number for verification. It usually takes about 15-20 minutes. In some situations, a live video call may be required to verify a new user’s identity. Once you finish signing in to or creating an account with ID.me, you will be redirected back to the portal’s user registration page and prompted to enter some profile information. Once you’ve entered the required information, click “Register” and you will be directed to your portal account’s home page. Portal Account Sign-in: To sign-in to an existing portal account, navigate to the website at <hhs-ecape- portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.” You will be redirected to ID.me and prompted to sign in with multi-factor authentication to your ID.me account. Once you have signed into ID.me, you will be transferred to your portal account’s home page. Exhibit 49.2 – How to Upload Documents via the OMHA e-Appeal Portal (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) To upload documents to an existing Level 3 appeal, sign-in to the portal. From the main page, select the “Upload Additional Documents to an Appeal tab” on the left side of the page. Enter the OMHA appeal number and then select the file(s) you wish to upload to the appeal by clicking the “Add Another File” button. Once the OMHA appeal number is entered and the desired files are added, click “Submit.” A confirmation pop-up question will appear, asking “Are you sure you would like to submit the Attachment?” Click “OK.” After you select “OK,” a screen will appear to confirm the files were uploaded. The appeal number and the file name(s) uploaded will be listed. You will also receive an e- mail confirmation. Note: Use caution when entering the appeal number to avoid adding files to the wrong appeal. Avoid using any spaces before or after the appeal number. The Administrative Law Judge and team assigned to the appeal will receive an alert that a document was uploaded to the appeal. You may upload multiple documents, but each file is restricted to 50MB. If the file is larger than 50MB, it will need to be broken down into smaller files and then uploaded. The following file types can be uploaded: PDF, RTF, Word, Excel, PowerPoint, BMP, JPEG, PICT, TIFF, CSV, and XML. Exhibit 50 – UPIC and I-MEDIC Fax Cover Sheet (Rev. 13595; Issued: 01-26-26; Effective: 02-26-26; Implementation: 02-26-26)