In case you haven't heard, on June 30, 2015, the Provider Reimbursement Review Board (PRRB) issued ALERT 11 - REVISION OF PRRB RULES REINSTATEMENTS AND WITHDRAWALS (see pages 44-46 in link) notifying Providers about amendments to PRRB Rules 46 and 48, which were effective July 1.
The Rules
Rule 46.1 provides among other things, that a “Provider may request reinstatement of an issue(s) or case within three years from the date of the Board’s decision to dismiss the issue(s)/case or, if no dismissal was issued, within three years of the Board’s receipt of the Provider’s withdrawal of the issue(s)”. Rule 46.2 provides reinstatement “As a Result of Administrative Resolution or Agreement to Reopen.” Rule 46.3 provides reinstatement for “Dismissals for Failure to Comply with Board Procedures”, which are only granted in rare circumstances and a provider must give “good cause” as to why the dismissal was outside of their control.
Rule 48 provides that a “Provider’s request to withdraw an issue(s) or case must be in writing.” It also provides that “[i]t is the Provider’s responsibility to withdraw:”
“an issue(s) or case that the Provider no longer intends to pursue;”
“an issue(s) or case in which an administrative resolution has been executed and attach a copy of such administrative resolution;”
“an issue(s) for which the Intermediary has agreed to reopen the final determination for that issue(s) and attach a copy of the correspondence from the Intermediary where the Intermediary agreed to that reopening; and”
“a case in which all issues have been handled, whether by resolution, transfer, dismissal, or withdrawal.”
SCA Take
Our focus should be on Rule 48 first, as a Provider must request a withdrawal before there will be a need to request a reinstatement under Rule 46. As stated above, Rule 48 has been amended to allow a Provider the right to request a withdrawal for an issue(s) for which the Intermediary or Medicare Administrative Contractor (MAC) agreed to reopen and requires that the Provider attach “correspondence” from the MAC showing the agreeance. While a Notice of Reopening is preferred, only time will tell what the PRRB will deem as acceptable “correspondence.”
In Practice
Let’s say a Provider has withdrawn their appeal or issue(s) pursuant to Rule 48 (3), but the MAC did not process the reopening. Now, Rule 46.2 kicks in and allows that Provider the right to reinstate the appeal or issue(s) since the MAC agreed to reopen, but failed to process that reopening and issue the revised Notice of Program Reimbursement. The PRRB should reinstate that appeal or issue(s) as long as the Provider requested reinstatement within 3 years from the date the Board withdrew the appeal or issue(s) and again provided the “correspondence” where the MAC agreed to reopen that appeal or issue(s).
If you have any questions about Alert 11 or would like to discuss further, please do not hesitate to contact SCA at 972-732-8100. Alert 11 means at some point there was an Alert 10. Miss it? Read about it here!
