Other Fields
Agency Scheme: 
HHSOPRRB0005
ADJUDICATION STRUCTURE
Hearing Level: Basic Structure
Name of Hearing Office (local name): 
Provider Reimbursement Review Board
Name of Hearing Office (global name): 
Department of Health and Human Services: Provider Reimbursement Review Board
Sub-Agency/Bureau/Division:: 
Housed within Centers for Medicare and Medicaid Services, Office of Hearings and Inquiries, CMS Office of Hearings
Hearing Officer #1 (Title): 
PRRB Board Member
Are administrative appeals permitted from final decisions at the hearing-level stage?: 
Yes (All Types of Cases)
Comments/Notes on Adjudication Structure: 

The PRRB adjudicates reimbursement disputes (primarily with respect to an audited cost report) between Medicare Part A providers and Medicare Administrative Contractors. Current reimbursement issues presently before the PRRB relate to payments for disproportionate share hospital adjustments, Medicare bad debts, and graduate medical education. In cases in which the CMS Administrator does not issue a decision affirming, reversing, or modifying a PRRB decision, judicial review of the PRRB decision is available. Where the CMS Administrator does issue a decision affirming, reversing, or modifying a PRRB decision, judicial review of the Administrator's decision is available. See 42 USC 1395oo(f)(1); 42 CFR 405.1877(a)(2).

PROCESS & PROCEDURE - General Information
Are private parties permitted to have representation at hearings?: 
Yes (All Types of Cases)
Who may serve as a private party representative?: 
Either
About what percentage of private parties were represented at hearings (FY2013)?: 
95.00%
Is the agency permitted to have representation at hearings?: 
No
Regulations/rules of practice for hearings (please include CFR citations): 
42 C.F.R. §§ 405.1835-1840. Provider representatives and Medicare contractors (not agency officials) appear at hearing
Other published guidance for hearings (if any): 
42 USC 1395x(v)(1)(A) and PRRB Rules (see website: cms.gov/regulations-and-guidance/review boards/prrb review)
PROCESS & PROCEDURE - Pre-Hearing Procedure
Is discovery permitted by either party at the hearing-level stage?: 
Yes (All Types of Cases)
Briefly describe the scope and type(s) of discovery available (e.g., depositions, interrogatories, etc.): 
Depositions, interrogatories and document requests are allowed.
Does the hearing officer have subpoena authority?: 
Yes (All Types of Cases)
Are ex parte contacts prohibited?: 
Yes (All Types of Cases)
Are parties provided notice of hearing?: 
Yes (All Types of Cases)
How far in advance of the hearing date is notice typically provided?: 
180 Days
PROCESS & PROCEDURE - Hearing Procedure
What types of hearings are permitted at the hearing-level stage?: 
Written (Document-Only) Hearing
In-Person
Phone
Please provide the approximate percentage of each type of hearing relative to the total number of hearings (FY2013)
Written (Document-Only) Hearing: 
20%
In-Person: 
65%
Video: 
0%
Phone: 
10%
How is the type of hearing selected: 
By Agency
By Private Party
Please describe: 
Parties may request written or phone hearing but such method must be approved by Board chairperson and approvals are based on the nature of the case (legal vs. documentation), the number of witnesses, etc.
How many hearing officers preside at each hearing?: 
Four or More
Is witness testimony permitted at hearings?: 
Varies by Case
If "Varies by Case," please describe: 
Witness testimony is permitted in in-person hearings. This question is not applicable to document-only hearings.
Can parties cross-examine witnesses?: 
Varies by Case
If "Varies by Case," please describe: 
Witness cross-examination is permitted in in-person hearings. This question is not applicable to document-only hearings.
Can third-parties submit amicus briefs and/or evidence?: 
No
Are hearings recorded and/or transcribed?: 
Yes
Are hearings open to the public?: 
Varies by Case
If "Varies by Case," please describe: 
In-person hearings are always open to the public. This question is not applicable to document-only hearings.
PROCESS & PROCEDURE - Post-Hearing Procedure
Who typically drafts the decision at the hearing-level stage?: 
Staff Attorney
Other
If "Other," please specify (drafts): 
PRRB/Office of Hearings Staff are responsible for drafting decisions based on Board Members determinations in decision conferences. Board Members review each draft and make changes as they deem necessary.
Who has authority to issue final decisions?: 
Other
If "Other," please specify: 
PRRB Chairperson signs final decisions and directs staff to physically release final decisions.
Do agency regulations or guidance provide time limits for issuance of final decisions?: 
Yes (Some Types of Cases)
If "Yes," please specify these time limit(s): 
Requests for Expedited Judicial Review (EJR) must be granted or denied within 30 days of receipt of a complete provider request, pursuant to 42 C.F.R. 105.1842(e)(3)(i). All other decisions issued by the PRRB have no regulatory or statutory deadline for issuance.
About how long does it take on average—as of FY2013—to adjudicate claims/cases at the hearinglevel stage (i.e., from case filing: 
1 095 Days
Is judicial review available after issuance of a final decision?: 
Yes (Some Types of Cases)
PROCESS & PROCEDURE - Case Management
How are claims/cases processed at the hearing-level stage?: 
Differentiated Case Management
Please briefly describe your case management practice(s) at the hearing level stage: 
OH utilizes combination of scheduling techniques including "first in- first out," accelerated hearing requests, scheduling/grouping by issue type and combining fiscal year at issue, and taking requests of respective parties into consideration.
Does the agency permit web-based electronic filing of hearing-related briefs or other documents?: 
No
Are final decisions published and/or posted on the agency website?: 
Yes (All Decisions)
If "Yes (Some Decisions)," how does the agency determine which final decisions to publish/post? Please briefly describe: 
PRRB substantive decision and non-interlocutory jurisdictional decisions pursuant to 42 CFR 405.1835 and 1840.
Do agency regulations/rules of practice specify the contents of the administrative record at the hearing-level stage?: 
Yes (All Types of Cases)
If "Yes," please provide citation(s): 
42 CFR 405.1865
Do agency regulations/rules of practice provide for closure of the record at the hearing-level stage (subject to applicable exce: 
Yes (All Types of Cases)
If "Yes," please provide citation(s): 
42 CFR 405.1875(c)(4)
PROCESS & PROCEDURE - Comments
Comments/Notes on Hearing-Level Process & Procedures (Optional): 
In cases in which the CMS Administrator does not issue a decision affirming, reversing, or modifying a PRRB decision, judicial review is available. See 42 CFR 405.1877(a)(2).
ADJUDICATORS
Total # of Hearing Officers: 
5
ADR: General Information
Is ADR available at one or more points during the hearing process?: 
Yes
If "Yes," when is ADR available?: 
Pre-Hearing
Is ADR a mandatory or voluntary process?: 
Voluntary
What type(s) of ADR are available?: 
Mediation
Who conducts the ADR?: 
Other
If "Other," please specify:: 
Board Staff members trained in ADR process mediate independently from Board member decision making process.
Regulations/rules of practice governing ADR process (please include CFR citations): 
PRRB Rule 43
ADR – Summary Statistics
Comments/Notes on ADR Statistics (Optional): 
Traditionally, 90 to 95 percent of issues settle at mediation or thereafter without the need for hearing. Cases which are mediated often contain large groups of issues and providers. Particular issues may be withdrawn, settled, or transferred to other appeals.
CASELOAD STATISTICS - Summary Statistics
Total # Cases Filed/Opened (FY2013): 
3 907
Total # Cases Decided/Closed (FY2013): 
1 833
Total # Cases Pending (End of FY2013): 
7 124
CASELOAD STATISTICS - Supplementary Statistics
Does your agency maintain annual caseload statistics for this hearing office by case type (e.g., discrimination complaint, licen: 
No
Verified by Agency: 
Verified