/>iThe Medicare Learning Network (MLN) again held a call to provide updates on the Low Volume Appeals (LVA) Settlement Option.
The LVA settlement option is being offered to providers and suppliers with fewer than 500 Part A and B claims pending as of Nov. 3, combined, where no single claim appeal exceeds $9,000. These appeals will be settled at 62 percent of the net allowed amount.
We provide highlights of the key points made by CMS staff during this March 13 call, including that the 15-day window to act within each step of the LVA settlement process refers to 15 business days, not 15 calendar days as previously stated. This change is important because it gives the appellant additional time to respond.
General information
• CMS is willing to settle with as many appellants as possible, so encouraged appellants to submit EOI.
• FAQs are forthcoming regarding Medigap coverage.
Eligibility
• $9,000 maximum is the billed amount per appeal (in total for the appeal), not per claim under the appeal. If over $9,000: Settlement Conference Facilitation Process expansion is expected to launch in April 2018, and providers can submit settlement conference facilitation requests for higher billed amounts.
• The LVA settlement option is only available for fully denied claims, and all claims on an appeal must be fully denied. Claims approved at lower level are not eligible.
• If a claim is part of a Medicare Part A settlement, it can still be eligible for LVA settlement so long as all other LVA settlement eligibility requirements are met.
• Medicare Advantage claims are not eligible.
Expression of Interest (EOI) submission
• For NPIs ending in an even number, EOIs will still be accepted but must be submitted as soon as possible.
• The definition of a “representative” is an attorney or other representative guiding an entity through the LVA settlement process. A “point of contact” is an individual at the provider entity coordinating the financial aspects of the appeals for provider. CMS asked appellants to include the facility address not just the representative’s address.
• Appellants should submit EOIs to see if the appeals are eligible.
Spreadsheet and Agreement
• Spreadsheet contains only potentially eligible appeals, and it is the appellant’s job to verify that those appeals actually do or do not meet the eligibility criteria.
• Agreement will be sent to appellant via email.
Eligibility Determination Request (EDR)
• CMS will reply within 30 days.
• Reminder that only 1 EDR can be submitted per NPI, so submit all changes with the EDR.
• There is a 15-day window for either side to take action within each step of the LVA settlement process – without a timely response the appellant will be considered to have abandoned and will be removed from the process. If appellant cannot take action within 15 days, then must communicate with CMS so that CMS can work with the appellant on the submission timeline. CMS clarified that the 15 days refers to business days, not calendar days as instructed during the last call.
• Subject line for EDR emails requires three items: NPI, appellant name, “EDR.”
• CMS warned again NOT to attach PHI with the EDR. An example of proper EDR supporting documentation is proof of change of ownership and non-affiliation with prior NPI.
• CMS offered that the EDR process allows local MACs to open lines of communication if any questions arise during the LVA settlement process.
Maily H. Hoang contributed to this article.
