Administrative Appeals

90.3 – Administrative Appeals (Rev. 246, Issued: 09-14-18, Effective: 12-17- 18, Implementation: 12-17-18) The applicable Medicare contractor shall issue a Cap Determination Letter to notify hospice providers of the results of the Medicare contractor’s cap calculations and to serve as the provider’s Notice of Program Reimbursement (NPR). If there is a cap overpayment, there shall be an accompanying demand for repayment. As indicated in 42 CFR 418.311, a hospice that believes that its payments have not been properly determined may request a review from the applicable Medicare contractor or the Provider Reimbursement Review Board (PRRB). Each determination of program reimbursement shall include language describing the provider’s appeal rights. The above described letter, serving as the provider's determination of program reimbursement, shall include the following language: “This notice is the Medicare contractor’s final determination for purposes of appeal rights. If you disagree with this determination, you may file an appeal, in accordance with 42 CFR 418.311 and 42 CFR, part 405, subpart R. The appeal should be filed with either the applicable Medicare contractor or the Provider Reimbursement Review Board (PRRB), depending on the amount in controversy. Appeal requests must be in writing and be filed within 180 days from the date of this determination.”