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Omha-agreement-of-participation-05-30-19 FORM OMHA Settlement Conference Facilitation

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
SETTLEMENT CONFERENCE FACILITATION
AGREEMENT OF PARTICIPATION
Please submit this agreement, along with your completed SCF Request Spreadsheet, to
OMHA_SCFAppeals@cms.hhs.gov
.
Handwritten signatures are required for this form. If you are an individual with a disability that would prevent you from entering a
handwritten signature, please use the accessible version of the Settlement Conference Facilitation Agreement of Participation available
on the OMHA website at
www.hhs.gov/omha
.
E-mail submission of all materials is mandatory. Please attach your signed Agreement of Participation in PDF format.
Settlement Conference Terms
Instructions: Appellants please complete the section below.
I understand and agree to the following:
•
An individual authorized to sign a binding agreement on behalf of the appellant(s) must be present at the settlement conference
session and the request for Settlement Conference Facilitation will be closed if an authorized individual does not appear at the
conference;
•
The appellant has not filed for bankruptcy and/or is not expected to file for bankruptcy in the future;
•
I understand that the settlement agreement may be void if the appellant has filed for bankruptcy or is expected to file for
bankruptcy in the near future;
•
Regardless of whether a settlement agreement is reached, I will not seek fees under the Equal Access to Justice Act (EAJA);
•
I understand the Centers for Medicare and Medicaid Services (CMS) will not pay fees under EAJA;
•
I agree to limit discussion of the appeals in my Settlement Conference Facilitation Spreadsheet to the Settlement Conference
Facilitation process. I verify that the appeals on the spreadsheet meet the Settlement Conference eligibility requirements;
•
I agree that I will not separately contact any individual within any division of CMS or its contractors regarding such
appeals throughout the duration of the Settlement Conference Facilitation process;
•
I understand that the U.S. Department of Justice must approve any proposed settlement agreements that involve appealed
claims with billed charges in excess of $100,000 or an appeal(s) of an extrapolated overpayment in excess of $100,000;
•
If a settlement agreement is reached, it will be binding and not appealable;
•
If a settlement agreement is reached, by signing the agreement, I will be agreeing to withdraw all of the requests for an ALJ
hearing and/or requests for Medicare Appeals Council review and not pursue further appeals for the items or services covered by
the settlement agreement;
•
If a settlement is reached, the settlement does not exempt the appeals from review for potential fraud and any civil or criminal
actions that commence as a result of such a review; and
•
I understand that these terms apply to all of the providers/suppliers listed in the Provider/Supplier Identification section of this
Agreement of Participation.
Appellant Signature Appellant Printed Name Date
OMHA (06/19)
PAGE 1 OF 4
PSC Publishing Services (301) 443-6740.
EF
Appointed Representative Acknowledgement
Instructions: Required completion if the appellant(s) representative will be signing the settlement agreement on behalf of the appellant(s).
The representative identified below is authorized by the appellant(s) listed in the Provider/Supplier Identification section to participate in
the Settlement Conference Facilitation process and sign an agreement on behalf of the appellant(s). The representative has advised the
appellant(s) that any agreement signed on the appellant(s) behalf will be binding on the appellant(s), and will include an agreement that
the appellant(s) is withdrawing all of the requests for hearing or review and not pursuing further appeals for the appeals covered by the
settlement agreement. The representative fulfilled his/her duty to advise the appellant(s) of the consequences of withdrawing a request for
an ALJ hearing and the subsequent dismissal that will result from that action. Further, the representative agrees to limit discussion of the
appeals under review to the Settlement Conference Facilitation process. The representative will not separately contact any individual
within any division of CMS or its contractors regarding such appeals throughout the duration of the Settlement Conference Facilitation
process.
Appellant Signature Appellant Printed Name Date
Representative Signature Representative Printed Name Date
OMHA (06/19)
PAGE 2 OF 4
Settlement Conference Facilitation Confidentiality Agreement
Instructions: This section must be completed by every individual who will be in attendance at the settlement conference, regardless of
actual participation in the settlement conference. Failure of every individual in attendance to complete this agreement will result in rejection
of an appellant’s request for settlement conference facilitation.
If additional signature lines are needed, please download and complete the Addendum to Settlement Conference Facilitation
Confidentiality Agreement.
As parties to this settlement conference, we voluntarily agree to mediation in the conference. We understand that mediation may be
terminated at any time by either the parties or by the facilitators.
The facilitators have no authority to decide any case and are not acting as advocates or attorneys for any party. The parties have a right
to representation during the settlement conference.
The confidentiality provisions of the Administrative Dispute Resolution Act (ADRA) apply to this settlement conference. The ADRA focuses
primarily on protecting private communications between parties and the facilitator. Under ADRA, a party’s oral communications to the
facilitator during settlement conference mediation are protected. Written communications which a party prepares for mediation and gives
only to the facilitator are also protected. Notwithstanding the above, there are exceptions to the confidentiality provisions in ADRA in the
OMHA Settlement Conference Facilitation Process.
In unusual circumstances, a court can order disclosure of information that would manifest injustice, help establish a violation of law, or
prevent harm to public health and safety. Further, information concerning fraud and criminal activity or threats of imminent harm will not
be considered confidential in this settlement conference.
Additionally, by signing this agreement, CMS and the appellant agree not to publicly disclose any information or statement
provided by the other party during the course of the pre-settlement conference or settlement conference unless the disclosure
is in response to a lawful request (e.g., discovery, subpoena, or FOIA).
No party shall be bound by anything said or done at the settlement conference, other than agreement to these terms and conditions,
unless a written settlement is reached and executed by all necessary parties. By signature below, we acknowledge that we have read,
understand, and agree to the terms and conditions stated herein.
Appellant or Representative Signature Appellant or Representative Printed Name Date
Appellant or Representative Signature Appellant or Representative Printed Name Date
CMS Authorized Staff Signature CMS Authorized Staff Printed Name Date
CMS Authorized Staff Signature CMS Authorized Staff Printed Name Date
OMHA Facilitator Signature OMHA Facilitator Printed Name Date
OMHA Facilitator Signature OMHA Facilitator Printed Name Date
OMHA (06/19)
PAGE 3 OF 4
Settlement Conference Facilitation Agreement of Participation Provider/Supplier Identification
Instructions: This section must identify every appellant whose appeals will be addressed in the settlement conference. The terms listed in
the preceding pages of the Agreement of Participation will apply to every appellant listed in this section. You may attach a separate list if
you require more space.
For the purposes of Settlement Conference Facilitation, an appellant is defined as a Medicare provider or supplier that has been assigned
a National Provider Identifier (NPI) number.
Appellant Name NPI
OMHA (06/19)
PAGE 4 OF 4
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Completed 16 February 2020

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