Appeals (§486.314)

2819 - Appeals (§486.314) (Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) Involuntary Termination/Non-Renewal of Agreement: An OPO may appeal an involuntary termination or non-renewal of an agreement on substantive and procedural grounds. CMS sends a notice of initial de-certification determination to the OPO which contains the reasons for the determination, the effect of the determination, and the OPO’s right to seek reconsideration. The notice letter informing the OPO of de-certification and impending termination must include the appropriate appeal rights as well as instructions on how to file a request for reconsideration. Reconsideration of a De-certification: An OPO has 15 business days from receipt of CMS’ notice of de-certification to seek reconsideration from CMS if it is dissatisfied with the de-certification determination. The OPO reconsideration request must state the issues or findings of fact with which the OPO disagrees, the reasons for disagreement and factual support for each finding with which they disagree, and the reasons for disagreement. The OPO may submit factual support for each findings with which they disagree as well as additional information and arguments as to why it should not be decertified. CMS then evaluates the submitted information to determine if the de-certification decision is upheld or reversed. An OPO must seek reconsideration before it is entitled to seek a hearing before a hearing officer. If the OPO does not request reconsideration from CMS, or fails to submit its request timely to CMS, the OPO has no right to further administrative review and the de-certification is final. CMS Reconsideration Determination: A written reconsidered determination is made by CMS within 10 business days of the request for reconsideration. This determination will affirm, reverse or modify the initial de-certification determination and the findings on which it was based and will determine whether the submitted documentation and information was sufficient to support a change in the initial decision. If the determination decision is reversed or modified, CMS notifies the OPO in writing with a revised Form CMS-2567 to reflect the revised findings. If the decision is not reversed or modified, but is affirmed, CMS notifies the OPO in writing of the decision, including what materials CMS reviewed and why the submitted documentation did not justify a reversal or modification in the initial decision to de- certify. Additionally, CMS informs the OPO that it will not be eligible to compete for the current service area or any other service area opened for competition. CMS will augment the administrative record to include any additional materials submitted by the OPO and a copy of the reconsideration decision, and sends the supplemented administrative record to the CMS hearing officer. If the OPO timely seeks further administrative review (hearing), CMS forwards the initial request for reconsideration and all supporting documentation to the hearing officer. Administrative Hearing: An OPO that wishes to appeal the reconsideration decision of CMS must file a written hearing request within forty (40) business days of the receipt of the notice of CMS reconsideration decision. If a hearing request is not submitted or received timely by CMS, than the OPO has no further right to appeal or other administrative review. The Administrative Appeal Process is handled through the Office of Medicare Hearings and Appeals. Administrative Record: The administrative record consists of, but is not limited to, (1) factual findings from the survey(s) on the OPO conditions for coverage; (2) data from outcome measures; (3) rankings of OPOs based on the outcome data; and (4) correspondence between CMS and the affected OPO. The hearing officer sends the administrative record to both parties within ten (10) business days of receipt of the OPO’s written request for hearing.