Provider Reimbursement Memorandum

Memorandum

To: Potential Employer
From: Name Withheld
Date: April 14, 2014
Re: Guide to the responsibilities of Health and Human Services Centers for Medicare and Medicaid, Provider reimbursement, and the Provider Reimbursement Review Board

PURPOSE

The purpose of this Memorandum is to acquire a better understanding of the responsibilities of Health and Human Services Centers for Medicare and Medicaid Services (the “Agency,” or “CMS”), Provider Reimbursement,1 and the Provider Reimbursement Review Board (the “PRRB” or “Board”). This memorandum focuses on (1) recent Medicaid and Medicare legislation; (2) the process of becoming a Provider;2 (3) the reconsideration process for prospective Providers; (4) the appellate review process of Provider reimbursement decisions; (5) the role of the PRRB; and (6) alternatives to administrative or appellate review of Provider reimbursement decisions.

ISSUES: What is Medicare and Medicaid? How does an individual or entity become a Medicare or Medicaid Provider? What is the
An FI’s denial of a Provider’s reopening request is not subject to administrative review by the PRRB or to judicial review.105 Because neither the Secretary nor CMS is a party to the FI’s determination, reopening in this scenario is required only when the Provider (or a related organization of the Provider) has itself procured the determination by fraud or similar